April 2001 Issue 12

Field ExchangeEmergency Nutrition Network

East Timor: Money for WorkKenya Refugee Programme evaluationRemittances in SomalilandNutritional Screening in Ethiopia:Involving the community

guidelines for selecting and establishingthese ‘lesser-tried’ types of emergencyfood security intervention.

Although not necessarily their main focusthis edition of Field Exchange alsocarries a number of pieces whichhighlight some of the difficulties andissues connected with the assessmentphase of responding to food emergencies.

An article by Kate Sadler of Concernshows how anthropometric surveys inWolayita, southern Ethiopia effectivelyidentified the need for general ration andselective feeding programmes as well asdemonstrating the impact of theseinterventions so that decisions aboutphase out could be made. In contrast,Ken Baileys article about a food crisis inAmhara region of north west Ethiopiasuggests that the resources devoted toanthropometric surveys to determineintervention impact might be better usedelsewhere. He reasons that once theintervention had begun it would makemore sense to set up a community basednutritional surveillance system. Thiswould help tackle longer-term nutritionalproblems connected with feeding andhealth practices once the emergency wasover. His suggestions for establishing thistype of surveillance were supported bythe INGO in question.

An article by Robin Wheeler from WFPKenya describes how one of the drivingforces for improving food security co-ordination in Kenya was the lack ofstandardisation in assessment approachadopted by agencies and, in someinstances, poor adherence to standardsurvey protocols resulting in poor qualitydata.

The article by SC (UK) about amicronutrient deficiency disease outbreakin Wajir district of Kenya explains howthere was confusion about casedefinitions for the multiple micro-nutrientdeficiency disease. This theme of casedefinitions for micronutrient diseases isreturned to in the agency profile on theInternational Emergency Refugee andHealth Branch (IERHB) of CDC. IERHBare hoping to undertake research leadingto a more standardised case definition ofscurvy.

A number of points regarding assessmentemerge from the various piecesmentioned above;

i) there is still room for improvingtechnical capacity in assessments, e.g. inestablishing more standardised case-definitions for micro-nutrient deficiencydiseaseii) dissemination and uptake of ‘best’assessment practice remains problematic,iii) there is a need to develop guidelineson the appropriateness of assessmentapproaches for different contexts.

Finally, we would like to thank ourreaders for the great response to ourrequests for articles, research and newsfor this edition of Field Exchange. Apartfrom making our job easier it is verygratifying to see the enthusiasm out therefor contributing material. Please keep itcoming.

Dear Readers

Two topical themes emerge in this editionof Field Exchange. The first is foodsecurity interventions which do not involvefree hand-outs of food aid; the second isissues connected with nutritional foodsecurity assessments. An article by MikeParker about a cash for work programme inEast Timor shows how a non-food aidresponse to food insecurity can beextremely effective. There are fewdocumented experiences or studies of cashinterventions in emergencies although anumber of donors seem to be getting moreinterested in this type of response. Co-incidentally, Oxfam UK are undertakingresearch into cash interventions inemergencies based on a set of case studies.The study will examine issues likeeconomic impact, the effect on genderrelations, and cost effectiveness (seeresearch section page 3).

Humanitarian agencies have grappled withsome of the more intractable operationalproblems of emergency food aidprogrammes for many years, e.g. targetingand interruptions in the food aid pipeline(see SC (UK) article on Wajir in thisedition). More recently however a numberof agencies have begun to consider whetherin some situations cash based interventionsmight be more appropriate. Marketinterventions, whereby prices of key foodcommodities are moderated by propping upthe market, are also relatively unexploredas an emergency response to food crisis.Conceivably, market support may be amore cost-effective method of targeting themost vulnerable than handing out free foodaid. In general few NGOs have experienceof, or guidelines on emergency foodsecurity strategies which do not involvefree food donations, e.g. cash for workprogrammes, livestock off-take or marketsupport programmes’ . There are even alack of operationally useful guidelines forFood for Work Programmes in spite of thefact that there have been many experiencesof implementing FFW during emergencies.Guidelines would have come in very usefulin Kenya during 1999 when a number ofmulti-agency assessment teamsrecommended widespread food for workprogrammes in response to the droughtaffecting large parts of the country. Therecommendations were made without anyassessment of the institutional capacity toset up and manage FFW programmes or ofthe number of beneficiaries that couldrealistically be served. In the event only ahandful of small-scale FFW initiativescould be implemented

During the drought which affected centralTanzania at the end of the 1990s, an INGOin conjunction with government attemptedto implement a market support programme.This intervention was recommended as ameans of getting around problems oftargeting food aid in a large widelydispersed rural community. Theintervention failed as the tonnages of maizereleased onto the market did not have thedesired impact in reducing prices. Withhindsight the analysis leading to therecommendation for this intervention wasprobably flawed as it did not take intoaccount parameters like size of market andoverall effective demand. These, and otherexperiences point to the growing need forresearch leading to the development anddissemination of basic principles and

Contents

Field Articles10 Involving communities in nutritional screening in

Ethiopia 15 Outbreak of micronutrient deficiency disease:

did we respond appropriately? • Postscript/Response to SCF Wajir article • Kenya drought emergency operation 1999 - 200119 Rapid impact on malnutrition through a multi-

faceted programme in Wolayita, SouthernEthiopia

23 Money for work in East-Timor 26 Feeding the unborn babies 28 Development of Kenya Food Security

Coordination System (KFSCS)

3 Research• Addressing the nutritional needs of older people

in emergency situations: ideas for action • Assessment of community based targeting from

a gender perspective • Remittances and their economic impact in post-

war Somaliland • Adults and adolescents: assessment of

nutritional status in emergency-affectedpopulations

• Cash interventions as an alternative to food aid • Conflict: a cause and effect of hunger

11 News• Launching the Iron Deficiency Project Advisory

Service (IDPAS)• Ready to learn?• Training courses and refresher workshops on

Nutrition in Emergencies, how to adequatelymeet our training needs?

• ALNAP: facilitating lessons learned • USAID releases commodity reference guide• IBFAN raises awareness on infant feeding in

emergencies • Fighting hunger on all fronts: AAH speak out in

a new publication• New distance learning course on ‘Nutrition in a

humanitarian context’• Update your bookmarks! • WFP-the essential ‘Food and Nutrition

Handbook’• US tries to head off UN plan to reform sanctions

14 Letters

22 Agency ProfileInternational Emergency and Refugee HealthBranch in CDC

25 EvaluationsJoint WFP/UNHCR evaluation of Kenyan refugeeprogramme

26 Revised MSF nutrition guidelines III

31 The backpage

3

Research

Addressing thenutritional needsof older people

in emergencysituations:

ideas for actionSummary of Review1

Help Age International (HAI) has produceda preliminary review of the nutritionalneeds of older people in emergency

situations. This is part of an ongoingcommitment by HAI to develop assessment tools,methodologies and approaches in all aspects ofnutrition interventions for older persons inemergencies. The review is based on the premisethat older people are a sub-group of thepopulation whose needs must be addressed moresystematically in emergency contexts.

The document was prepared by Annalies Borrel aconsultant with Valid International (UK) after athorough review of recent scientific literature andemergency nutrition guidelines, consultation withNGOs and use of practical case studies. Thedocument addresses issues of nutritionalrequirements of older people and examines thesein light of current emergency food and nutritioninterventions. It also provides a preliminaryframework for the design of emergency nutritioninterventions for the purpose of piloting andreview. It is hoped that the document will befurther developed based on additional case-studies and further lessons learnt fromprogramme experience. In view of thecomprehensive nature of this review only someof the findings can be represented in thissummary.

Key Findings

General Principles

While older people are commonly accepted asbeing a vulnerable or potentially vulnerablegroup in emergency situations, at presenthumanitarian interventions often ignore olderpeople’s specific needs, using systems thatdiscriminate against and on occasion, underminetheir capacity to support themselves.

Context and individual-specific risk factors willdetermine the nutritional status of older people.In emergency situations, the changes that impactdirectly on older people’s nutritionalvulnerability includes disruption or loss of socialstructures, family separations, stressful events,the need to adopt coping strategies and increasedpublic health risks.

There are numerous challenges that need to beovercome before the needs of older people can beaddressed more effectively. These include; arecognition that older people are a heterogeneousgroup of people whose capacities and needs varygreatly between individuals and betweensituations and the positive contributions thatolder people have within communities, includingduring emergency situations.

The United Nations principles for Older Persons(resolution 46/91), which was adopted by theGeneral Assembly in 1991, addresses issues ofindependence, participation, care, self-fulfilmentand dignity. While these principles provide auseful overall framework for action, the reportdefines more specific principles that can beapplied to the design of nutrition interventionsfor older people in emergency situations.

Nutrient requirements

The report discusses the nutrient requirements forolder people in relation to younger adults. Whileenergy requirements for older people, in generaldecrease, the need for micronutrients does not.There are many factors causing an increase inrequirements for micronutrients and in somecases, micronutrient deficiencies among olderpeople. These include; a general decrease inenergy intake, a reduction in intake of nutrientdense foods, a lower secretion of intrinsic factor,a high incidence of chronic disease and gastro-intestinal bleeding. However, much of theresearch findings, largely based on studies onolder people, in industrialised countries, remainequivocal.

In summary, it is recommended that older peopleconsume:

1 Addressing the Nutritional Needs of Older People in Emergency Situations. This preliminary report was prepared by AnnaliesBorrel (with support from Valid International) for HelpAge Africa Regional Development Centre (ARDC)

ABDULHADY HAJI / HELPAGE

• Foods that are nutrient-dense in vitamins andminerals.

• Vegetables and fruitsthat are deeplycoloured, for provisionof folate andantioxidant nutrients.

• Dairy products e.g. milk, for the provision ofadequate amounts of calcium and vitamin D.

• Adequate amounts of nutrient-rich foods such as;fish, dried beans, eggs and nuts. Variety in thesefoods is important but selection will be based onfactors such as: availability, cost, chewability,individual preference and ease of preparation.

• Foods that are high in dietary fibre, such as fruitand vegetables.

• Relatively higher volumes of fluid, since thirstsensation is decreased in older people.

Emergency general ration

In theory, the recommended per capita general rationdoes meet the nutritional requirements of olderpeople in terms of energy, fat and protein. Energyrequirements for older people generally decrease incomparison with younger adults. However, theminimum per capita energy requirement of(2,100kcal), when provided in the form of food-aidcommodities such as maize, beans and oil, isinadequate in terms of meeting the micronutrientneeds of older people.

There are also physical, social, and programmedesign factors which increase the risk of older peoplesuffering from inadequate food intakes in emergencysituations. These include:

An inadequate assessment of needs at the outset: theinvolvement of older people in decision-makingprocesses concerning food aid needs and programmedesign is frequently lacking.

Poor physical access to the ration: distances to foodcollection points in centralised distribution systemsare often too great, there are inappropriate queueingsystems and the elderly may be left out of theinformation loop about the general ration distribution.

Constraints in food processing and preparation:whole grains cereals and beans are difficult toprepare needing longer cooking time and involvingthe collection of water and fuel.

Limited opportunities for accessing food throughcomplementary coping strategies: rarely does thegeneral ration alone fulfil the nutritional needs ofemergency-affected populations. Additional food is

usually accessed through mechanisms such asinformal trade and labour, fishing, labour activities inexchange for food, etc. Older people often do notexperience the same opportunities for thesecomplementary activities as those of younger adults.

A number of recommendations for actions to addressthese inadequacies are outlined in the report. Theseinclude:

• Involve older people as key-informants duringassessments and collect information on thenutritional status of older people.

• Provide no less than 50g of blended food perperson per day as part of the general ration.

• If quantities of blended food are limited, childrenunder five years old and older people should beprioritised over other population groups.

• Ensure physical access to the general ration byestablishing mechanisms to inform older people oftheir entitlements to food rations as well as theintended distribution schedule.

• Decentralise distribution sites and prioritise olderpeople at distribution points.

• Older people must have sufficient support or meansto access sufficient fuel and water for cooking.

Selective Feeding Programmes

Malnourished older people should be given equalaccess to nutritional rehabilitation centres as those ofother demographic groups. In many cases however,older people will not necessarily respond tonutritional treatment, especially those who aresuffering from underlying chronic illness. In thiscontext, the design of nutritional rehabilitation andsupport programmes should enable older people whoare at nutritional risk to be given the opportunity toremain within their communities with the support ofcommunity-based assistance. This strategy will aimto strengthen existing support structures, allow olderpeople some dignity and independence as well ascreate opportunities for older people to re-establishthemselves in their traditional roles withincommunities. In this context, the Community-basedSupport Programme (CSP) within the overallframework of selective feeding programmes for olderpeople is most important and should be a priority.This programme focuses on identifying specific riskfactors on an individual basis and strengtheningfamily and community support mechanisms.

Elements of overall programme framework

There is no need to create separate selective feedingprogrammes for older people but rather, expand and

4

Research

The framework for programme design of selectivefeeding programmes for older people is based on sixelements.

Community and nutritional assessment• The nutritional vulnerability of older people will be

determined largely by the absence or break-down ofcommunity social support structures; these social riskfactors are best defined by the communitiesthemselves and are usually context specific.

• The acceptability and effectiveness of the programmewill be enhanced if the community’s older members,are involved in its design and have an understandingof its objectives.

• Where qualitative information shows that olderpeople are likely to be more vulnerable than otherpopulation groups, an assessment of the nutritionalstatus of older persons will be included as part of abroader assessment.

Out-reach activities• Many of the most vulnerable older people who are

often not visible and unable to present themselves,such as those who are too weak and/or have nofamily, will need to be accessed through communityhealth workers.

• Older people require information on their entitlementsand it cannot be assumed that they have access togeneral information systems.

Nutritional rehabilitation: selective feeding • Based on anthropometric and clinical criteria, older

people have access to therapeutic or supplementaryfeeding.

• Nutrition rehabilitation is based on well-establishednutrition and medical protocols, similar to those foradults and children.

• Discharge is based on objective criteria and thecapacity of the family/community to continue toprovide support.

• Those older people who are chronically ill and/or whoare not responding to nutritional treatment arereferred to a community-support programme.

Individual case-assessment • During the period of rehabilitation, an identified

‘carer’ or family member is involved in therehabilitation process.

• Specific nutritional-support tasks that are required toprevent a deterioration in nutritional status in thehousehold following discharge, are identified.

Community-support programme: • Community-based worker provides support to the

‘carer’ and/or family to ensure support tasks are beingcarried out and older people have access to basicdaily needs in the community.

• The nutritional status of older people is monitored. • Support to the carer or family is provided in terms of

training, emotional support, feedback and motivation. • The capacity of older people to re-integrate into the

community is monitored.

Longer-term care• Once social support structures have been rebuilt, food

security has improved or an appropriate ‘safety-net’ isin place, older people must have information on, andaccess to longer-term support structures.

Admission criteria for older people in selective feeding programmes***

* Except those older people presenting with bilateral famine oedema (regardless of MUACstatus), who should be referred to a clinician.

** With the purpose of preventing any further deterioration in nutritional status.*** Based on Collins et al (2000)

Category Action MUAC (mm) Clinical criteria Social criteria

Normal nutritional status Do not admit* > 185 +/- -

High nutritional risk Community Support Prog.** > 185 +/- +

Moderate malnutrition Supplementary feeding 160 - 185 - +/-

Severe malnutrition Therapeutic feeding 160 - 185 + +/-

Severe malnutrition Therapeutic feeding < 160 +/- +/-

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5

Research

adapt existing supplementary and therapeutic feedingprogrammes to include older people in situationswhere there is a demonstrated need.

In any given situation, the objectives and design ofsupplementary feeding for older people will need tobe clearly defined. In particular, where nutritionalimprovement and discharge is not an expectedoutcome for older people in a supplementary feedingprogramme, this should be explicitly stated at thedesign stage of the programme. Small, decentralised,community-based kitchens may be feasible in somesituations and may be the most effective andacceptable approach.

Not all older people are equally vulnerable andtargeting is necessary, especially where resources arelimited. There is no universally agreed index and cut-offs for defining acute severe and moderatemalnutrition in older people. For pragmatic purposes,

it is recommended that a combination of Mid-Upper-Arm Circumference (MUAC), clinical and social-riskcriteria, is used to define admission criteria. Thesocial criteria used in the targeting process will becontext-specific and based on the outcome of acommunity assessment of risk factors or causes ofmalnutrition, for older people.

The nutrition protocols for treatment of severe andmoderate malnutrition among older people are similarto those of children and adults. Additional issues mayneed to be addressed in the design and managementof selective feeding programmes for older people,such as; providing adequate resting facilities andprivacy, training staff with adequate skills incommunication and emotional support, respectingolder people’s wishes to die in their communities andensuring that the nutritional rehabilitation centre isnot perceived and used as a hospice-type institution.

During the rehabilitation phase, family andcommunity support systems are identified and allindividuals are referred to the Community SupportProgramme for follow-up.

The monitoring and evaluation criteria will need to beadapted. While standard nutritional and healthrecovery indicators may be applied to some extent,other important indicators such as the community andfamily support outcomes and the community’sperception of its effectiveness, will be equallyimportant.

The finalised report is due to be published by Help AgeInternational. For copies of the report please contact: DollineBusolo, Regional Nutritionist, HelpAge International, AfricaRegional Development Center, P.O. Box 14888 Westlands,Nairobi, Kenya. Tel: 254 2 444289/4469691/449407. Fax; 2542 441052 or Email: helpage@net2000ke.com

During 2000 community based targeting ofemergency food aid was introduced intoKenya. WFP were instrumental in promoting

and implementing the community-based system(CBTD). (see article “Development of Kenya FoodSecurity Coordination System (KFSCS) by RobinWheeler for a full description of CBTD systems).Previous systems of emergency food aid targeting inKenya were acknowledged by most to be grosslyinefficient as more or less everyone received a foodaid ration. As a result ration receipts were extremelysmall (as little as 1 kg per person per month ofmaize) and therefore of limited use to genuinely foodinsecure families.

During September 2000 WFP undertook anassessment of the CBTD at three sites in Marsabitdistrict. There were 70 distribution centres in thedistrict with 80% of the population targeted for foodaid. A large component of the WFP assessment wasgeared towards determining the extent to which WFPpolicy commitments regarding women were beingfulfilled as part of this programme.2 The findings ofthe assessment provide useful insights into genderrelated aspects of this increasingly employed mode oftargeting emergency food aid.

The project document3 for the WFP emergencyprogramme in the region - EMOP 6203.01 commitsitself to addressing gender related inequalities by:

• Ensuring that all community-level relief committeeshave at least 50 percent women and where possiblea female chairperson

• Including a gender awareness component in thetraining on CBTD

• Building awareness in gender sensitive facilitationskills

• Registering and distributing food directly to women• Recruiting both female and male food monitors.

The WFP assessment was carried out using PRAtechniques including key informant interviews andfocus group discussions.

The following questions were asked in theassessment:

• How many men and women are on the reliefcommittee

• What is the role of the relief committee• What roles do the men and women play - are they

different or the same• Who calls meetings• Who sets the agenda• What is the group’s perception of the CBTD system• What is their perception of the role of women in

the CBTD system - what are the particularproblems that women face in taking an active,participatory role

Key findings of the gender related aspects of theassessment were as follows:

1. At the beginning of the EMOP men were resistantto women taking a leadership role on the ReliefCommittee although they accepted the participationof women because it was policy.

2. As the EMOP has proceeded they have graduallyseen that women’s participation has brought a senseof transparency and accountability to the distributionprocess.

3. The women stated that they were nervous at thebeginning but they are now more confident andappreciate the support that they have got from themen on the Relief Committee.

4. Women identified illiteracy and patriarchal cultureas challenges to their level of participation.

5. They stated that most of the chairpersons andsecretaries are male.

6. The men complained about the time the womenmembers of the RC spend on distribution when theyalso have domestic work to undertake. The womendid not see this as a problem and said that theyusually arrange for other members of the householdto support them.

7. The men complained about the lack ofremuneration for relief committees. The women saidthat they were used to voluntary work.

8. Overall, relief committees members interviewedstated that their status in the village had improvedand they were confident that the targeting process isfair and the most vulnerable are being reached.

Recommendations given by the community included:

1. More leadership and gender training for the ReliefCommittees.

2. The lead NGO should keep monitoring the numberof women on the Relief Committees.

3. More advocacy for the community and otherdevelopment agencies on the role of ReliefCommittees especially concerning the participationof women.

1 Gender Assessment of Selected Relief Committees inMarsabit District-A field mission report by Hendrica Okondoand Kate Newton. WFP Kenya - September 2000.2 Amongst these policies are commitments to: i) Target relieffood distributions to households, ensuring that womencontrol the family entitlement in 80 percent of WFP handledand sub-contracted operations, ii) Take measures to ensurewomen’s equal access to and full participation in powerstructures and decision making.3 Kenya EMOP 6203.01: Assistance to Drought-Affected Peoplein Rift Valley, North Eastern and Coast Provinces of Kenya

Assessment ofcommunitybased targetingfrom a genderperspectiveSummary of Report1

6

Research

An enduring difficulty of assessing needsamongst certain emergency affectedpopulations has been uncertainty about

whether the affected population are sent income fromrelations abroad or living in other parts of the country(remittances), and if so, how much. It is extremelydifficult to quantify or monitor remittances assources, and channels are diverse with cash flowsoften taking place in the ‘black’ economy.

A recent study in Somaliland has thrown some lighton this subject. The study examined the role ofremittances provided by a large global diaspora ofmigrant workers and refugees in post-warSomaliland. Field work was conducted in 1998/9 andexamined trends in the size, source, and means ofremittance transfer as well as the use of remittances,their role in livelihoods and in the country’seconomic recovery. Sample households wererandomly selected from a list of recipients obtainedfrom telephone and money transfer companies. Asemi-structured questionnaire was used. Data wasalso obtained through detailed interviews withleading money transfer agencies on the amount ofmoney that goes through these channels and detailsof individual transfers.

Estimating remittances in Somaliland is problematicfor a number of reasons. First, remittances aretransferred in a number of forms and throughdifferent channels. They can be cash in kind, e.g.cars, furniture, jewellery, clothing or electronic goodsand they can also be channelled through trustedmerchants or hand carried by migrants when theyvisit home. Secondly, there is no data available on theglobal numbers of migrants and refugees fromSomaliland. Third, Hawaalado (money transfer

companies) who are responsible for a significant partof transfers, sometimes deliberately under-report thesize of the flows for fear of government interferencein the form of taxes or new regulations.

Remittances originate mainly from migrant labour inthe Gulf and more recently an exodus of refugees tothe West. The growth of telecommunications inSomaliland and of remittance agencies has greatlyfacilitated the transfer of money. The study found thatthe value of remittances is estimated at some US$500 million annually - around four times the value oflivestock exports. In fact the livestock export ban bySaudi Arabia in 1998 in response to the Rift Valleyfever outbreak in Kenya and southern Somalia waspredicted to lead to a collapse in international tradeand market exchange. It was feared that the shortageof hard currency needed to finance imports wouldspell disaster for the country. The ban lasted 14months and the number of animals exported fromSomaliland fell sharply from 2.9 million in 1997 tojust over 1 million in 1998. However, this failed toaffect the volume of imports mainly becauseremittances financed the entire import bill.

The study found that the average annual remittancereceived by households was $4,170 and that therewere approximately 120,000 recipient householdsthroughout the country - roughly one third of thepopulation. These estimates of remittances areconsistent with other studies and transfers tocountries such as Eritrea and Sudan with similarmigrant populations. However, it is important to notethat the distribution of annual transfers is highlyskewed due to large sums of money received by arelatively small proportion of households.

It appears that remittances are heavily concentrated inurban centres. While the majority of households inHargeisa rely on remittances for their livelihoods,less than 5 percent of rural households receive moneytransfers from abroad. It is particularly less importantin pastoral households. For agro-pastoralists internalremittances from migrant workers in urban areas aremore important than international ones. Because ofrecent changes in the demographic structure ofmigrants, an increasing proportion of those receivingthis kind of income are women.

The effect of remittances on households has beenconsiderable in providing secure livelihoods. Thestudy found that in urban areas many people had ahigh standard of living due to remittances. However,there is evidence to show that remittances haveincreased income inequality. Migrant workers andrefugees generally come from better-off families whocould afford the relatively high investment costsinvolved in sending someone abroad. The going ratefor an employment visa and ticket to the Gulf isabout $3000 while a ticket and travel documents toEurope or North America cost roughly $5000.Therefore it is mainly those families who can affordto invest in migration that receive remittances.

One of the conclusions of the study was that theselarge capital flows have contributed to rapideconomic recovery in post-war Somaliland and thedevelopment of a dynamic private sector.

1 Remittances and their Economic Impact in Post-warSomaliland (2000) Ismail. I. Ahmed. Disasters, 2000, 24 (4),pp 380-389.

Remittances and their economicimpact in post-war SomalilandPublished paper1

War affected Somalia - Tarabuunka IDP Camp, Mogadishu.

PIETERNELLA PIETERSE/CONCERN

7

Research

In July last year the ACC/Sub-committee onnutrition published two reports on theassessment of nutritional status in

emergencies. One report deals with adults andthe other with adolescents.3

Adults

This report describes simple techniques suitablefor the assessment of the nutritional status ofadults aged 20-60 years in emergency-affectedpopulations. The report makes preliminaryrecommendations stressing that there is noconsensus on a definitive method to assess adultundernutrition and that more research is required.

Main findings

Surveys and population levelassessments of chronic undernutrition

The BMI may be used to estimate the prevalenceof chronic undernutrition in a population surveyusing the classification system below

Classification of chronic underweight categories BMI(Kg/m2)

Normal >= 18.5

Grade 1 17.0-18.4

Grade 2 16.0-16.9

Grade 3 <= 15.9

In order to account for changes in body shape theCormic Index (sitting height/standing height)must be taken into account and standardised for,when comparing the BMI of differentpopulations.

MUAC may also be used to assess the prevalenceof chronic undernutrition at the population level

Screening severely undernourished adults

BMI is inappropriate for this purpose as it isaffected by oedema and body shape and difficultto measure in any particular situation. MUAC incombination with clinical signs should thereforebe used to screen adult entrance into feedingcentres using the following classifications.

For admission to therapeutic feedingcentres

i) MUAC < 160 mm irrespective of clinicalsigns

ii) MUAC 161-185 mm plus one of thefollowing:• bilateral pitting oedema• inability to stand• apparent dehydration

iii) Famine oedema ( i.e. oedema demonstrableup to the knee) alone as assessed by a

clinician to exclude other causes.

Additional social factors can be included in themodel. The relative weighting of these must bedetermined locally; for example whether youneed one, two or three additional social factors totip the balance in favour of therapeutic ratherthan supplementary care.

For admission to supplementary feedingcentres

MUAC 161-185 mm and no relevant clinicalsigns or few relevant social criteria

These suggested standards should only be usedas a starting point and adapted according to thesituation specific context.

Adolescents

The current WHO recommendations to comparethe BMI of individual adolescents with areference population made up of adolescents inthe US using the 5th centile of this reference as acut off point to define undernutrition may not beappropriate. Surveys using theserecommendations have found unrealistically highlevels of adolescent undernutrition.

There are several difficulties with anthropometryin adolescents; for example:

• body proportions, including indices usingweight and height measurements change withage, making it necessary to compare anindividual to adolescents in a referencepopulation who are of the same age. As aresult, age must be collected on personsscreened for admission to feeding programmesor measured as survey subjects. Adolescents inmany emergency affected populations do notaccurately know their ages

• body proportions change with sexualdevelopment. The age at which sexualdevelopment occurs differs in differentpopulations and complicates the comparison ofsubjects from one population to adolescents ina reference population

Possible solutions

These problems affect all anthropometric indices.The following adjustments may allow betterestimates:

• better methods of assessing the age ofattainment of key pubertal landmarks mayallow adjustment for difference in maturationage between survey and reference populations.

• Cormic Index may to some extent be used toadjust for ethnic differences in bodyproportions - however this technique has notbeen studied in adolescents.

• a new international reference consisting ofadolescents from 6 countries and a new methodof determining cut-off points may alleviatesome of the biases from using a referencepopulation for a single country.

Preliminary recommendations

i) Until better methods can be developed andvalidated, screening for severe undernutritionin order to determine the need for therapeuticfeeding should use clinical criteria.

ii) In surveys, some correction for different agesof sexual maturation should be carried out ifthe age of sexual maturation differssubstantially between the survey andreference population.

For pre-pubertal adolescents, weight for heightcould be used as the anthropometric index andcompared to revised weight for height tablescurrently in use.

For post-pubertal adolescents, BMI could beused as the anthropometric index and comparedto a new international reference population.Appropriate cut-off points could be used toidentify malnourished individuals.

iii) Regardless of which index is used, cut-offpoints are age-specific; as a result age shouldbe collected as accurately as possible on alladolescents measured during screening orsurvey activities.

iv) The reference population of Americanadolescents, currently recommended byWHO for use with BMI should not be used.

v) Adolescents should not undergo nutritionalassessment in isolation. A large discrepancybetween the estimated level of undernutritionin adolescents and other populationsubgroups should stimulate investigation ofthe validity of the methods and results of theadolescent assessment.

vi) In order to assess the methods andcomparability of surveys, all survey reportsshould describe in detail the anthropometricindex used, how measurements were taken,which reference population was used, howindividuals were compared to this reference,and the cut-off points used to define variousdegrees of undernutrition.

1 Adults: Assessment of nutritional status in emergency-affected populations; July 2000 Collins.S, Duffield.A andMyatt.M2 Adolescents:Assessment of Nutritional Status inEmergency-Affected Populations, July 2000: Bradley. A,Woodruff, and Duffield. A3 Reports available from ACC/Sub-Committee on Nutrition,20, Avenue Appia, 1211 Geneva 27, Switzerland. Email:accscn@who.ch or online athttp://acc.unsystem.org/scn/Publications/RNIS/

Adults and adolescents: assessment of nutritional status in emergency-affected populationsNew publications1,2

As part of a “Food aid Policy and StrategyProject” Oxfam GB is undertaking researchinto the use of cash as an alternative to food

aid. Whilst Oxfam GB has increasingly engaged incash programming, e.g. in Asia and Africa, it hasbeen difficult to judge the effectiveness and impact ofthese programmes. Other organisations haveundertaken cash interventions, however, as withOxfam GB, these have not been widely reviewed ordisseminated.

As part of the research Oxfam GB is interested incollecting information from organisations on cashbased interventions including cash for workprogrammes, free cash distributions and voucherdistribution. Existing literature suggests certain keyareas which the research will address.

Research Issues

Context

Contextual analysis will determine when and how itis appropriate to implement this type of programme.Three different disaster scenarios will be used toinform the research. These are slow onset naturaldisasters, such as drought, quick onset massdestruction such as cyclones or earthquakes andconflict. Using these scenarios an analysis of‘appropriate contexts’ for implementing cashinterventions will be developed.

Economic Impact

There are a number of ways in which cashinterventions could have an economic effect.

• There may be an inflationary impact on prices as aresult of improved purchasing power. However, theconsequences of this inflationary effect are notknown.

• Cash provision may act as a dis-incentive foreconomic activity. Economic activities that could beunder threat include agricultural production andtrade.

• Increases in prices can stimulate the trade of foodfrom food surplus areas into food deficit areas. Thishas been one of the key strategies adopted by thegovernment of India in famine prevention.

More information is required to determine the extentto which this occurs and the benefits.

Gender

The use of cash as a relief measure could have amajor impact on gender relations. Critics of theapproach have suggested that women will havelimited control over cash resources in contrast to foodaid.

Cost-effectiveness

Cost effectiveness is also an important factor toconsider when designing programmes. It has beenestimated that as a result of using cash, rather thanfood, in an employment generation programme inWolayita, Ethiopia, programme costs wereapproximately 50% of those which would have beenexpended had food been used instead. In 1999 a cashfor work scheme in Wajir district of Kenya (see FieldExchange 10), was judged to be the most cost-

effective recovery intervention compared to othermeasures taken in response to a severe droughtfollowed by floods.

Although often an acceptable intervention amongstcommunities, organisations often find it difficult tosecure funding from donor agencies. Theacceptability of this approach among donors hasvaried. The research hopes to shed light on why somedonors are more willing to fund cash interventions.

To aid this research Oxfam are collecting informationon cash interventions. Field Exchange readers canhelp by sharing experiences of such programmes. Ifyou have any information on any of the followingplease send it to the contact below.

Information sought on cash interventions includes:

1. Direct personal experience

2. Organisational perspectives and policies

3. Research carried out to date

4. Any form of documentation

5. Other contacts that might provide relevantinformation

Any information regarding cash interventions is welcome andshould be sent to Hisham Khogali (e-mailhkhogali@oxfam.org.uk). Alternatively contact him at OXFAM,274 Banbury Road, Oxford OX2 7DZ. Tel: +44 1865 312 176

8

Research

At Dili port, unloading ofWFP-supplied rice which willbe distributed at six differentcollection points in town.Workers from humanitarianagencies will be present tosupervise the distribution.

Cash interventions as an alternative to food aid Proposed Research

UNHCR/29343/10.1999/M. KOBAYASHI

9

Research

The International Food Policy Research Institute(IFPRI) is currently working on a review ofwhat is known about the linkages between

hunger. Some of the key findings of the review areoutlined in this summary.

At the end of 2000, violent conflict and its aftermathhad left nearly 24 million people in 28 developingand transition countries and territories food insecureand in need of humanitarian assistance. In addition,some 35 million war-affected refugees and internallydisplaced persons showed high rates of malnutrition.

Armed conflict leads to the destruction of crops,livestock, land, and water, and disrupts infrastructure,markets, and the human resources required for foodproduction, distribution, and safe consumption.Combatants frequently use hunger as a weapon: theyuse siege to cut off food supplies and productivecapacities, starve opposing populations intosubmission, and hijack food aid intended forcivilians.

The largest number of people in need of assistance(over 18.5 million) live in Sub-Saharan Africa. Thefigure below gives a breakdown of numbers on acountry by country basis.

In an earlier study IFPRI compared actual mean foodproduction per capita with “peace-adjusted” valuesfor 14 countries. The study found that in 13countries, food production was lower in war years,with declines ranging from 3.4 percent in Kenya toover 44 percent in Angola, with a mean reduction of12.3 percent.

The Food and Agriculture Organisation of the UnitedNations adopted a similar methodology to calculateconflict-induced losses of agricultural output in thedeveloping world as a whole over 1970-97. In Sub-Saharan Africa, agricultural losses accounted for 75percent of all aid received by conflict-affectedcountries and far exceeded the level of foreign directinvestment.

Even after wars have ceased, landmines continue toexact high costs in terms of human life, economic

and social development and agricultural production.Safe removal of 60-70 million unexploded landminesfrom 70 poor countries could expand agriculturallands; by 88-200 percent in Afghanistan, 11 percentin Bosnia, 135 percent in Cambodia, and 4 percent inMozambique.

As well as being a consequence of conflict, foodinsecurity can also lead to conflict. Most of thecountries currently experiencing conflict areclassified by FAO as “low-income food deficit” andhave high proportions of food-insecure households.

Environmental scarcities and food insecurity do notinevitably lead to conflict, but may provide anadditional impetus.

The trigger condition for violent conflict may benatural, such as a prolonged drought or economical,such as the change in price of the principal food (ricein Indonesia) or cash crop (coffee in Rwanda).

Econometric studies provide additional empiricalevidence of a link between food insecurity andviolent conflict. These find a strong relationshipbetween such indicators of deprivation as low percapita income, economic stagnation and decline, highincome inequality, and slow growth in foodproduction per capita on the one hand and violentcivil strife on the other

However, more research is needed to learn about thedynamics in which alleged environmental or foodscarcities have not contributed to violence.

Preventing cycles of hunger and conflict

Sustainable agriculture and rural development, withan emphasis on small farmers, should contribute toreduced risk of conflict in resource-poor areas andcountries. Broad-based development offers anantidote to the hopelessness that often leads toviolence and agricultural development assistanceshould be part of conflict-avoidance. Yet officialdevelopment assistance dropped 21 percent over1992-97, aid to Sub-Saharan Africa fell 13 percentduring 1994-97, and aid to agriculture plummeted

almost 50 percent in real terms over 1986-97.

Even as the total aid pie has shrunk, emergency needshave claimed ever larger slices, due to theproliferation of crises. In 1996, emergency assistancecame to 9.5 percent of all development aid, comparedto 3.5 percent in 1987, and 41 percent of food aidtonnages were devoted to emergency relief, asopposed to 10 percent in the 1970s.

The way in which projects are administered can alsobe important. Inappropriately administered aid canexacerbate tensions, as in Rwanda, where would-bebeneficiaries perceived unfairness in the distributionof agricultural-programs.

• Agricultural programs need to choose paths thatfoster cooperation among communities or rivalgroups and avoid negative competition leading toconflict.

• Programs need to be structured so that they createopenings for active participation by women andmen from zones of high conflict potential toparticipate in reporting, planning, and operations.

Conclusion

The linkages between conflict and food insecurity aremore and more evident in the post-Cold War era anda topic of concern to peace and food-securityadvocates inside and outside of government andinternational agencies. Food security anddevelopment programs must include conflictprevention and mitigation components. Savings fromconflict avoidance need to be calculated as “returns”to aid. Likewise, relief and post-conflictreconstruction programs need to have food securityand agricultural and rural development components ifthey are to help break the cycle of hunger andconflict.For further information contact: Marc J. Cohen at theInternational Food Policy Research Institute, 2033 K Street,N.W. Washington, DC 20006, USA or E-mail:m.j.cohen@cgiar.orgAlternatively visit their website at http://www.ifpri.org for thelatest IFPRI news and to access hundreds of food policyresearch reports.

Conflict: a cause and effect of hungerSummary of draft review1

0

1000000

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1 Conflict: a cause and effect of hunger. A draft review by IFPRI, compiled by Ellen Messer, Marc J. Cohen, and Thomas Marchione

Western Hemisphere

8%

Asia / Newly Independent States

14%

People in need of humanitarian assistance(As of November 15, 2000)

Worldwide total is 23,556,000

Sub-saharan AfricaPeople in need of humanitarian assistanceTotal is 18,526,000

Sub-Saharan Africa

78%

10

Field Article

Ibegan working as a volunteer nutritionist for aninternational non-governmental organisation(INGO) in July 2000. The INGO had been

supporting rural development work in 3 districts(total population 518 000 in year 2000) of North-West Ethiopia (Amhara region) for 15 years. In 1999there was near-total crop failure in both rainy seasons(belg and meher) and in the first half of 2000 the belgrains came too late for normal planting. This meantthat there was almost no harvest for three successiveseasons.

In response, the INGO provided a general ration(wheat, CSB and cooking oil) for approximately halfthe households from July to November 2000inclusive. Targeted households were selected on thebasis of wealth ranking and identified throughrepeated consultations between Farmers Associationleaders, the district administration and the INGO.

• This response effectively averted famine. • There was virtually no displacement of households

or consumption of famine foods.

The organisation wanted to monitor the impact of thefood relief on nutritional status through samplesurveys repeated monthly. Because of lack ofmanpower it wasn’t possible to do this monthly so

one survey was carried out in August (before the fooddistribution in late July could have had anysignificant impact) and a second in mid-October.

August survey findings

In the August survey two districts had a moderaterate of wasting in children <5 years (approximately7% were below- 2 z-scores WfH and WfL) while inthe third district the rate of wasting was far higher at16% (<-2z-scores). This implied that there wereabout 2500-3000 wasted children in each district.

Adult nutritional status was also measured. The meanBMI was low - near 20.0 kg/m2 combined for menand women. But there was no correlation betweennutritional status of children and adults in the samehouseholds. (This was interpreted to mean that otherfactors e.g. ‘young-child’ feeding practices andincidence of diarrhoeal disease played a moresignificant role than food availability in theprevalence of wasting in young children.)

Two months on...

In October the prevalence of wasting was more orless the same although the situation in one districtimproved while in another it deteriorated - apparentlydue to spread of dysentery. Apart from overall foodshortage, poor feeding practices (identified in surveyson young-child feeding) appeared to have animportant role in continued malnutrition amongst thispopulation.

As the new harvest was expected in November, andthe rainfall and agricultural conditions up to thenwere fairly good, an improvement in the situationwas expected in subsequent months. However, myview was that i) the level of wasting was likely toremain above 5% - with aggravating factors(especially diarrhoeal disease) and ii) the appropriateresponse should include at least health and nutritioneducation, focusing on the prevention of diarrhoeaand improved feeding practices for young children.With current practices most children begin solidfeeding after 12 months and breast-feeding is veryprolonged. Meals are given to children about 3 timesdaily.

The conventional approach at this point in anemergency project cycle would have been to continuewith sample nutrition surveys e.g. at 3-monthlyintervals. However, this would not have readily pavedthe way for action other than another round of reliefdistribution when/if the prevalence of malnutritionrose above a certain point.

Involvingcommunitiesin nutritionalscreening inEthiopiaBy Ken Bailey

Ken Bailey worked on acontractual basis for WHOGeneva from 1991 to 1997 andfor a considerable part of thattime had responsibility for the

“nutrition in emergencies” sub-programme.Since leaving Geneva Ken has worked forTearfund/UK in Southern Sudan, the UnitedMission to Nepal and another INGO inEthiopia.

Highlands of NW Ethiopia (showing highland, middle highland and lowland levels)- Ken Bailey

tumultuous scenes at food distribtuion sitesKen Bailey

11

News

Surveillance versus surveys

I recommended that it would be more useful toimplement a total community based nutritionalscreening with a nutrition education programmetargeted at households with wasted children ratherthan repeating cross-sectional nutrition surveys. Thiswould involve training volunteers at the level of eachhamlet (gott) which consists of about 50 households.At present community health agents (CHAs) arefound only at the farmers’ association level (5,000-10,000 people).

A programme was subsequently prepared to trainvolunteers at gott level to:

i) Measure weight and length and record it on aspecially designed WfL chart - one chart for eachgott with measurements repeated every 3 months.

ii) Carry out education on prevention of diarrhoeaand optimal feeding practices for young childrenin households where a wasted child was found.

Supplementary foods could also be provided forthese children if found necessary.

Involving the community

Meetings were held with all leaders of farmers’associations to explain how child malnutritioncontributed to child mortality, and how to identifymalnourished children and counsel the households.The leaders of the associations would thereforeeffectively manage the total community screening ofyoung children on a continuing basis. Theywelcomed this approach and accepted the challenge.

The volunteers at gott level were to be trained byhealth staff of the INGO, the CHAs and communitydevelopment agents who operate in each farmers’association.

It seemed to me that it would be much moreproductive to involve the communities themselves ina survey process thereby achieving full communitycoverage, rather than to carry on with traditionalsample nutritional surveys. In this way the long-termnutritional problems would be more comprehensivelytackled from within each community.

I also came to believe that sample nutrition surveysof emergency-affected populations may often yieldresults that are in the range where educational actionand perhaps targeted supplementary feeding areappropriate responses. It would be good under thesecircumstances to consider one further step -organising community-based total screening ofvulnerable groups - as a regular “development”phase of the initial relief effort. This could then beplanned from the beginning as a follow-up response.Otherwise large numbers of wasted children mayremain in the communities with no effective actiontaken unless/until the prevalence rises again to thelevel where universal supplementary feeding (i.e.blanket) or generalised ration distribution are seen asthe appropriate responses.

For more information contact Ken Bailey atbaileykv@ozemail.com.au

news

The International Nutrition Foundation(INF), in collaboration with theUnited Nations University (UNU)

with funding from the MicronutrientInitiative (MI) will establish the IronDeficiency Project Advisory Service(IDPAS). Based in Tufts University Schoolof Nutrition Science and Policy, the IDPASaims to expand a proactive networksupporting those working on the preventionand control of iron deficiency and irondeficiency anaemia in developing countriesand countries in transition.

IDPAS will help individuals and projects toobtain specific information on any matterrelated to iron in nutrition and interventionsfor prevention and control of iron deficiency.Potential areas of support include:

• advocacy and policy development,• problem assessment,• program design,• iron supplementation for all age groups,• food fortification including technical

issues related to enrichment mixes, costsand equipment,

• communication for dietary change,• intervention monitoring and programme

review.

The network also will help identify sourcesof technical expertise and funding.

IDPAS will work to facilitate

communication between field level andtechnical experts through their website, e-mail, fax, phone or courier. Its partnerorganisations include the MicronutrientInitiative, PAMM, ILSI, CDC, IFPRI,MOST, SUSTAIN, UNICEF, WHO, theWorld Bank, HKI, John Snow, BASICS,GTZ and others, as well as electronicdiscussion groups such as NGONUT and theIronlist.

IDPAS is concentrating initially on newlyinitiated or accelerating programs andprojects as well as a few well-establishedefforts to prevent and control iron deficiencyanaemia. Priority countries includeAzerbaijan, Egypt, Ghana, Indonesia,Kazakhstan, Kosovo, Kyrgyz Republic,Lebanon, Mongolia, Nigeria, Pakistan,Tajikistan, Turkmenistan and Uzbekistan.

Based on successful initial performance, theINF will expand this IDPAS service to thoseworking on iron nutrition related activities inall countries.

IDPAS encourages those working toimprove iron nutrition and reduce theprevalence of iron deficiency anaemia to getin touch.

Queries and comments about the network or onany matter related to improving iron nutritionshould be sent to Gary Gleason, IDPAS, 126 CurtisStreet, Medford, MA 02155 USA. Tel: (1-617) 627-2291. Fax: (1-617) 627-3688 or E-mail:ggleason@inffoundation.org.

Launching the Iron DeficiencyProject Advisory Service (IDPAS)

The Ready to Learn Centre at theAcademy for EducationalDevelopment (AED) has received

funding to support a pilot project inNutrition Education. This initiative is aimedat any interested agency involved innutrition rehabilitation programmes toimplement or support nutrition education inthe centre. Their ‘Ready to Learn’ staff canhelp field personnel develop simple learningtools for better early child development.These are then shared with children andcarers. Examples of how the ‘Ready toLearn’ personnel can help and train yourteams are:

• in selecting and inventing appropriatestories for educational purposes

• in finding ways to build on traditional

simple games• in designing short messages or discussions

about early childhood developmentactivities

• in developing community focus grouptopics or plans with field staff.

The ‘Ready to Learn’ team visit the centresyou are working in and help train your staffon the ground. AED require the participatingagency to facilitate communications andlogistics. This is a short-term initiative thatmay be of interest to field staff.

If you are interested in participating in this project,please contact Diane Lusk at dlusk@aed.org orSarah Dastur at sdastur@aed.org. Alternatively writeto the Academy for Educational Development, 1875Connecticut Avenue, NW, Washington, DC 20009-1202.

Ready to learn?

The survey must go on despite the rain! - Ken Bailey

12

News

NutritionWorks runs a three day course on‘Nutrition in Emergencies’ in collaborationwith International Health Exchange and

Merlin. The next courses will take place in Mayand November 2001.

This is limited, however, in that it can only give anoverview of the issues and cannot providecomprehensive practical training.

NutritionWorks is, therefore, considering expandingit’s repertoire of courses to meet the needs of boththose new to the field and those with experience butwho want to brush up on their skills. The followingtypes of courses/refresher workshops are beingconsidered:

1. An in-depth practical training course on Nutritionin Emergencies for those with no or very little fieldexperience. This course would last about 10 days(which could be in one block or for one day aweek for 10 weeks). The emphasis would be ondeveloping practical expertise (e.g. how to do ananthropometric survey/food and nutritionassessment, use of EpiNut etc.) and makeextensive use of case studies and field experiences.It would basically be an expansion ofNutritionWork’s existing 3 day course.

2. A one or two day refresher workshop forexperienced nutritionists. This would aim toprovide an update on new policy, guidelines, and

research findings (e.g. the latest on infant feedingin emergencies etc.). It could possibly bestructured around presentations with plenty of timefor group discussion and sharing of fieldexperience.

3. A short course on nutritional issues in food aid fornon-nutritionists (e.g. agency programme staff,food logisticians) who are involved with food-related programmes but who don’t have a technicalbackground in nutrition. The aim would be toprovide an update on nutrition-related issues tonon-technical staff (e.g. new forms of food aidsuch as blended foods, policy on distributing infantformula etc).

NutritionWorks would like to assess the demand forcourses by asking the Field Exchange readership torespond to the following:

• Does your agency offer training in nutrition inemergencies? If so, what type of training and is itsatisfactory?

• Do you think these kinds of courses/workshopswould be useful to you or your agency?

• Would you or your agency be prepared to pay toattend such courses/workshops?

• Would other kinds of courses/workshops/training bemore useful?

Send your responses and comments directly to Fiona Watsonat NutritionWorks, P.O. Box 27415, London SW9 6WD, UK. Tel:+44 0207-582-3603 or email: fwatson@cwcom.net

Arevised Commodities Reference Guide(CRG), dated December 7, 2000, wasreleased on USAID’s website and is available

for use and comment. It can be downloaded inPortable Document Format (PDF) at:http://www.usaid.gov/hum_response/crg/. The guideis a major revision and update of the original CRG,issued in 1988.

The CRG provides information on food commoditiesdistributed under Title II of Public Law 480 (P.L.480). This programme is administered by the UnitedStates Agency for International Development(USAID) in conjunction with the United StatesDepartment of Agriculture (USDA), and comprisesemergency and development activities. Since itsinception in 1954, the P.L. 480 Programme and otherfood assistance instruments have distributed 375million metric tons of US food commodities valuedat well over $50 billion. In 1990, the Congressamended the P.L. 480 legislation, re-asserting theUnited States’ intent to use its agriculturalproductivity to enhance food security in thedeveloping world.

The CRG is an information tool, providing relevantinformation about the food commodities used in TitleII programmes. All food commodities are available tothe P.L. 480 Programme as long as they are notdetermined to be in short supply by the US Secretaryof Agriculture, a determination that is made everyOctober (per Section 401(a) of the FAIR Act, 1996)by the Secretary of Agriculture.

The CRG is designed to provide organisations with adescription of available food commodities, theirnutritional values and physical properties, a guide toappropriate storage and handling, and importantgeneral information regarding their safe and effectiveuse as rations in Title II programmes.

The CRG provides information on the foodcommodities that are in general use in the Title IIprogramme in Part One (Title II Food AidCommodities and Fact Sheets) and information andexamples on selecting rations for differentprogramme scenarios in Part Two (Guidelines forSelecting Food Aid Commodities).

Part Two has been developed and includes Guidelinesfor Selecting Food Aid with an overview chapter andthe following modules:

• Maternal and Child Health Programmes • Food for Work • Food for Education • Non-Emergency Humanitarian Assistance • Emergency

USAID is interested in hearing from the readers ofField Exchange with comments on the recentlyreleased Guide.

For more information contact: Tom Marchione, Bureau forHumanitarian Response, U.S. Agency for InternationalDevelopment, 1300 Pennsylvania Avenue, NW, Washington,D.C. 20523E-mail: tmarchione@usaid.go

ALNAP:facilitatinglessons learned

The Active Learning Network forAccountability and Performance inHumanitarian Assistance (ALNAP) was

established in 1997 as an internationalinteragency forum working to improve learningand accountability across the humanitariansystem. Based in the Humanitarian PolicyGroup at the Overseas Development Institute inLondon, ALNAP maintains a database ofevaluative reports on humanitarian programmes.The Reports Database represents a uniquecollection and is a valuable resource for theinternational humanitarian system. It providesthe basis for synthesis or ‘meta’ studies on theresults of evaluations in relation to particularsectors, issues or responses in particulargeographical areas.

For example, at the time of the 1998 flooddisaster in Bangladesh, the findings ofevaluations of responses to previous floodevents in the country were e-mailed to ALNAPMembers and key donor and NGO actors inDhaka - an initiative that was valued by manymembers. In April 1999 the initiative wasrepeated in relation to previous evaluations ofprogrammes in the Balkans of potentialrelevance to ongoing operations in relation toKosovo. Currently over 260 reports have beencatalogued and the key sections of over 200 ofthese are maintained in fully searchable formaton the ALNAP website atwww.odi.org.uk/alnap.

ALNAP commissioned and supported activitieslast year included:

• Support for the preparation and publication ofan edited volume ‘Doing Evaluations ofHumanitarian Assistance’.

• Development of a proposal for a global studyto produce a good practice handbook on‘Consultation with and Participation byBeneficiaries and the Affected Population inthe Planning, Management, Monitoring andEvaluation of Humanitarian Programmes’.

• Development of the ‘Learning Office’ conceptthrough a field study in Orissa andcomplementary desk studies of Kosovo andEast Timor.

• A study mapping ‘accountability’ in relationto the international humanitarian system.

ALNAP’s workplan for 2000-02 is organisedaround three themes:

1. Making the Evaluation Process MoreEffective2. Strengthening Accountability Frameworks

within the Humanitarian System3. Improving Field-Level Learning Mechanisms

ALNAP’s membership now comprises 46 FullMembers (bilateral and multilateral donororganisations, UN agencies and Departments)and a growing number of Observer Members(currently 240) from NGOs and NGO umbrellaorganisations, the International Red Cross andRed Crescent Movement, selected consultants,academics and research institutes.For further information on ALNAP contact:John Borton, Coordinator, ALNAP Secretariat, OverseasDevelopment Institute, 111 Westminster Bridge Road,London SE1 7DJ. Tel: +44 (0) 207 922 0314 or Email:j.borton@odi.org.uk or alternatively access their websiteat www.odi.org.uk/alnap

Training courses and refresherworkshops on Nutrition in Emergencies, how to adequately meetour training needs?

USAID releases commodityreference guide

13

News

Action Against Hunger (AAH) discusstheir experiences of humanitarianinterventions aimed at eliminating or

preventing hunger in the newly publishedreport: The Geopolitics of Hunger 2000-2001‘Hunger and Power.’

Compiled by the Action Against Hungerinternational network, this publication draws ontheir experience, spanning twenty years,working with some of those populations mostaffected by humanitarian crisis.

AAH assert that each humanitarian crisis iscomplex and different and that in order toprovide adapted, efficient and tailored responsesto the needs that arise, it is essential to be ableto accurately analyse the situations in whichagencies operate and the true causes of hunger.

Most of this analysis comes to the sameconclusion: hunger is used as a weapon againstcivilian populations who are denied the mostbasic of human rights, the right to food.

AAH highlight that their technical expertise andcommitment alone are insufficient in suchscenarios and that there is therefore a need toalert the wider public and call for internationalaction beyond the humanitarian response toexpose and oppose such crimes.

Key issues that are tackled include:

i) The use of hunger as a weapon.This is demonstrated through experiences inSierra Leone, Somalia, Kosovo and othercountries.

ii) Confronting unjust food distribution:which strategies for humanitarianintervention?Humanitarian organisations may becomepawns in geopolitical games wherebyagencies must struggle to retain impartialityand independence when confronted withgovernments intent on serving their own

political interests. Questions that areaddressed include; How to react whenconfronted by criminal regimes? What arethe principles to be respected and the codeof conduct to be followed? What is the roleof humanitarian organisations in the presentworld of international relations?

iii) Food policies to eradicate hunger.Humanitarian assistance alone cannotprevent global malnutrition. Neverthelessthe role of such assistance should includeanalysis and resulting proposals for povertyeradication and advocating for efficient foodpolicies.

Part three of the publication provides ananalysis of policies that could be implementedto secure the right to food ranging from theLomé Convention to policies on increasingproductive capacity.

Also available from AAH is their: ActionAgainst Hunger international activity report,1999-2000.

The extensive report describes all ActionAgainst Hunger’s international activities andrelief programmes between 1999-2000. It aimsto give an insight into their approach to fightinghunger through describing types of programmeand design. The report also reviews ActionAgainst Hunger’s charter of principles, itsexpertise and integrated technical approach, aswell as the management of its resources.

Copies of The Geopolitics of Hunger 2000-2001 ‘Hungerand Power’ cost £16.50 and can be ordered directlyfrom EDS, 3 Henrietta Street, Covent Garden, LondonWC2E 8LU. Email: orders@edspubs.co.ukFor further information on both publications: contactAction Against Hunger UK, 1, Catton Street,London,WC1R 4AB. E-mail: aahuk@aah-uk.demon.co.uk

New distancelearning course on‘Nutrition in ahumanitariancontext’

Inspired by Action Against Hunger’ssuccessful in-house training, this newlylaunched course is designed for nurses,

midwives, doctors, dieticians and nutritionists,working or thinking about working in thehumanitarian field. The aim is to equip traineeswith the analytical and technical skills withwhich to tackle nutritional issues, at a pace thatis convenient to them.

Over a 6 month period, the course offerscomprehensive training on the causes,prevention, diagnosis and treatment ofmalnutrition, with the use of practical casestudies.

The course fee is £300 sterling. Interested applicants should contact: Sharon Wright,Action Against Hunger, 1 Catton Street, London, WC1R4AB. Tel: 44 207 8315858 or E-mail:s.wright@aahuk.org Closing date for completed applications is 30th April2001 and the course is scheduled to commence on14th May 2001.

IBFAN raisesawareness oninfant feeding inemergencies

The Infant Feeding inEmergencies group(IBFAN) is pleased to

announce the release of abrochure on Infant Feeding inEmergencies.1 The brochureaims to raise awareness about,and encourage an appropriateresponse to infant feeding inemergencies. It highlights the importance ofprotecting, promoting and supportingbreastfeeding in emergency situations. Thebrochure is intended for policy makers,programme managers and field workers fromagencies involved in emergency relief, donors,journalists and other interested parties.

Request for copies can be addressed to • Wemos, PO Box 1693, 1000 BR Amsterdam, The

Netherlands. Email: wemos@wemos.nl or• IBFAN-GIFA, PO Box 157, 1211 Geneva 19,

Switzerland. Email: info@gifa.org

1 Infant Feeding in Emergencies: IBFAN November2000.

Fighting hunger on all fronts: AAHspeak out in a new publication

Update yourbookmarks!

The ENN website has movedto a new URL:www.ennonline.net. As part

of the move, the site underwent acomplete redesign and we hopethat the new site’s structure willmake navigation easier. Due toexceptional demand, we also planto make available all thedocuments published by the ENNin PDF format as well as zippedarchives of the online issues ofField Exchange for easy offlinebrowsing.

14

News/Letters

Letter

s

Dear Field Exchange,

I find it very interesting to see that Field Exchange is publishing alot of informative articles on nutrition interventions in emergencies.At the same time it sets me thinking about ‘the invisible emergency’that is going on back home in Bangladesh and raises questions inmy mind about ‘when is an emergency an emergency.’

Bangladesh is a country of 128 million people with a land sizeapproximately two times that of Ireland. Although, Bangladesh isnot in the grip of what is topically called a complex emergency, thefact is that the nutritional status of the Bangladeshi population isamongst the worst in the world. In Bangladesh more the 50% ofwomen are stunted while 50% of infants are born with low birthweight (less than 2500g).1

Stunted growth amongst the women of Bangladesh is due to lack ofadequate caloric intake throughout the course of life. The averagedaily calorie intake of Bangladeshi people is 2085 Kcals (88% ofRDA).1 Amounts for those poor households below the average aretherefore by definition less while status of individuals within thefamily also leads to a reduced intake. Culturally women have lesserstatus in the family. Furthermore, their economic contribution to thefamily is not very visible so that intra-house hold food distributionsfavour men and male children. This is an everyday fact for womenin Bangladesh.

The 1996-1997 Bangladesh Demographic and Health Surveyrevealed that over half (52%) of mothers are acutely malnourished(i.e. BMI<18.5)2 while 17% were less than 145cm tall. Women’s lowheight is associated with reduced pelvic growth which increases therisks of difficult childbirth and higher maternal mortality. InBangladesh the maternal mortality rate is 4.5 per 1,000 and is one ofthe highest in the world.3 Smaller women are also at higher risk ofgiving birth to low birth-weight children.2

These statistics are very disturbing. Equally disturbing is the impactof inter-generational malnutrition on the physical and intellectualgrowth of future generations which has in turn ramifications fornational economic development and the cycle of poverty.

In Bangladesh there is not enough food for everyone but with properinterventions the prevalence of maternal malnutrition could bereduced. Globally, the problem is not lack of food but equity andappropriate intervention.

There is a pervasive tendency to ignore this type of invisible crisisand it’s underlying causes. Media attention will only be sparked bycatastrophe. I also believe that acute emergencies must be addressedbefore chronic ones and am aware that the main focus of thispublication is emergency nutrition interventions. However, while thetype of widespread maternal malnutrition evident in my homelandmay not fall into a conventional emergency category in my mind itis an undoubted emergency (albeit invisible) with a massive impactaffecting the entire country.

Yours etc.

Lovely AminPolicy Development and Evaluation Directory (PDED)Concern Worldwide, DublinE-mail: lovely.amin@concern.ie

1 Human Development Report, 20002 Bangladesh Demographic and health survey, 1996-19973 The State of the World’s Children

WFP-the essential‘Food andNutritionHandbook’

WFP have published, with collaboration from Nutrition Works,a ‘Food and Nutrition Handbook’ (2000). Aimed at all WFPstaff who are involved in the delivery of food assistance, this

document is designed as both a reference and training manual. Itshould enable staff to assess and analyse the nutrition situation in theircountry or region and help manage the design, implementation,monitoring and evaluation of interventions.

The handbook covers a range of topics that include: basic food andnutrition concepts, the process of assessing and analysing types ofnutritional problems and their causes, practical applications ofnutrition interventions, the range of nutrition related programmessupported by WFP, tools for planning an adequate ration, selectivefeeding modalities, general food distribution and the core principles ofnutrition information, education and communication as complementaryintervention strategies.

The Food and Nutrition Handbook is a valuable resource, easy to readand a great reference tool while in the field. WFP stress that thisdocument complements but does not replace other key material e.g.UNHCR, WHO documents or SPHERE Minimum standards.

For further information contact Anne Callanan at the Nutrition Unit, WFP, ViaCesare Giulio Viola 68/70, 00148 Rome, Italy. Tel: +39 06 65131 or Email:Anne.Callanan@wfp.org

US tries to head off UNplan to reform sanctionsIn the past Field Exchange has published a number ofpieces on the impact of international economic sanctionsof food security in countries like Iraq, Cuba and Haiti(Issues 4 and 9). The developments summarised belowmay therefore be of interest to our readers. (Eds.)

Concerned about the humanitarian impact of sanctions on civilianpopulations, the UN secretary general, Kofi Annan, set up aspecial committee last April to examine sanctions policy. The

committee was due to recommend a shift towards so called ‘smartsanctions’ that are more clearly defined and better targeted. But theUS, which is intent on maintaining tough sanctions against Iraq, withthe backing of Britain, will almost certainly succeed in cutting out twokey recommendations; one setting a time limit on sanctions and theother introducing majority voting on sanctions committees.

Critics claim that sanctions usually fail to undermine the targetedregimes and that the criteria for imposition and lifting of sanctions aretoo vague. In a draft copy of its report the committee says “sanctionsregimes, in particular the security council resolutions that enact them,must be carefully designed, clearly establishing their goals, identifyingthe targets, tailoring the type of sanctions imposed so that they areadequate to the situations specifying clear criteria that need to besatisfied in order for the sanctions to be suspended or lifted.”

Other committee recommendations include; targeting the finances ofleaders rather than the general population; greater punishment forcountries found to be breaking sanctions; and a “carrot-and-stick”approach which would see a gradual lifting of sanctions in response topartial compliance with UN resolutions. The committee also states;“Sanctions regimes should be designed to minimise the potential foradverse humanitarian impacts and to maximise the ability forhumanitarian goods and services to reach civilian populations.”

The committee recommends that food, medicine and medical suppliesbe excluded from sanctions regimes.

Guardian, Friday 9th February 2001, page 17 - Ewen MacAskill Diplomatic editor.

Patients at the Women's Training Centreclinic, Kamlapur slum, Dhaka, Bangladesh.(Pieternella Pieterse / Concern)

In September 2000 there was an outbreak of scurvyand what appeared to be dry beriberi in the west ofWajir District, North Eastern Kenya. This article

sets out to describe the outbreak and the response bythe international community and the government ofKenya. Lessons learnt from the experience are drawnout so we can better respond in the future to preventand control micronutrient deficiencies in emergencies.

Background

Since 1990 Wajir has suffered from a succession ofdisasters with droughts in 1992 and 1996/97, El Ninofloods in 1997/98 and ongoing tribal conflicts. With nosignificant rain since the El Nino rains the area isexperiencing yet another drought. The majority of thepopulation of Wajir are nomadic pastoralists of theSomali ethnic group. In February 2000 manypastoralists were forced to migrate long distances withtheir herds in search of water and pasture. Those whocould not travel the long distances, mostly women,children and the elderly, were left behind. Many otherpastoralists have been made destitute through loss oflivestock as a result of the El Nino floods, drought andconflict. This is particularly so in the west of Wajirwhere there is a large displaced population from theBagalla massacre of 1998. Since March 2000 there hasbeen an influx of people into the west displaced fromthe conflict in the north of the district. Those leftbehind when herds migrate and the displaced havesettled in peri-urban areas to benefit from relief and aredependent on food aid for their survival. All are at riskof food insecurity and malnutrition. A nutrition surveyin late September in the west and north of WajirDistrict found high levels of malnutrition in childrenwith a prevalence of 21.2% global acute malnutritionand 5.8% severe malnutrition1.

The Outbreak

In early September 2000 there were reports from thewest of Wajir that people had been experiencingsymptoms of weakness and pain in the lower limbs andjoints and in some cases peripheral neuritis andimmobility. A rapid assessment by the Ministry ofHealth (MoH) and Save the Children, UK (SC(UK))with technical advice from the Centre for DiseaseControl and Prevention (CDC) identified suspectedvitamin deficiencies.

Discussions with the community revealed that thesigns and symptoms observed had never beenexperienced before in this population. Interviews andclinical examination of 23 people affected found thatthe symptoms developed gradually and the duration ofsymptoms was from one to four months preceding thevisit. All sexes and ages were affected.

Symptoms experienced

Most individuals affected experienced weakness, non-specific weight loss, peripheral oedema and aninability to stand from a squatting position. Thesesymptoms could be attributed to protein energymalnutrition (PEM), vitamin C or thiamine deficiency.PEM was ruled out as all but one of the adultsexamined had mid upper arm circumferences greaterthan 18.5cm, the suggested cut off for moderatemalnutrition in adults2.

Seventeen people experienced symptoms of scurvy -specifically bleeding gums and swollen leg muscles orknees. Seven people experienced symptoms specific todry beriberi including stocking and glove sensorychanges, loss of reflexes, and in two cases, foot drop.Five experienced symptoms of both scurvy and dryberiberi.

Access to food sources

Those affected had typically lost their animals andhence their livelihoods because of drought, conflict orthe El Nino floods. All were living on the periphery oftown centres and the majority were displaced. All hadbeen eating an extremely limited diet of Governmentof Kenya relief maize and black tea from February toJune and had no milk or meat (their usual diet) sincethe herds had migrated away in February. Relief maizeprovided by the government provided only 9% ofenergy needs. Donor response to the emergency wasslow3 and a World Food Programme (WFP) generalfood ration (GFR) was not introduced until June.Pulses and oil were only added in July. Even with theGFR the diet remained deficient in energy, protein andmicronutrients. The food aid allocation was not basedon any assessment of the food security situation of thepopulation.

Until the introduction of pulses to the GFR the typicaldiet contained no vitamin C and even with theintroduction of pulses, the dietary intake of vitamin Cwas insufficient to prevent scurvy. The August dietaryintake of vitamin C was 1 mg whereas 6.5-10mg perday is required to prevent scurvy.4 Thiamine intake wasonly 22% of the Recommended Daily Allowance untilthe introduction of the GFR and did not meetrequirements until pulses were introduced in July.

Blanket SFP

In early September, a blanket supplementary feedingprogramme (SFP) was introduced providing a monthlyration of fortified corn soya blend (CSB) to all childrenunder five and pregnant and lactating women. Theinadequate GFR meant that the CSB was consumed bythe entire household, and not just the intendedbeneficiaries, and as such only lasted for two weeks

15

Field Article

Outbreak of micronutrient deficiency disease: did we respond appropriately?By Dianne Stevens, Patricia Araru and Buwa Dragudi, Save the Children (UK)

Dianne Stevens is anutritionist with a Mastersin Public Health andTropical Medicine. She hasbeen working for SC (UK)for the past two years inthe nutrition and foodsecurity sector and hasmost recently been anutrition advisor in Wajir.

Buwa Dragudi took overfrom Patricia asProgramme Manager. Bothwere involved inaddressing theseoutbreaks.

Patricia Araru worked asProgramme Manager forHealth during the start-upphase of the SCFresponse to thisemergency.

1 Save the Children (UK) and Ministryof Health, Kenya, Nutrition Surveyin North and West Wajir District,Kenya, October, 2000

2 Collins, S., Duffield, A., and Myatt,M. Assessment of nutritional statusin emergency-affected populations:adults., 2000, UN ACC/Sub-Committee on Nutrition

3 The Kenyan government’seconomic and political performancehas been a factor in donorreluctance to respond

4 WHO, Scurvy and its preventionand control in major emergencies,1999

16

Field Article

rather than one month. With the CSB thevitamin C content of the diet jumped from5% to 185% of the recommended intake. Thethiamine content of the diet was notsignificantly increased. All those withsymptoms reported an improvement after thefirst distribution of CSB e.g. those previouslybed-ridden were now at least able to walk alittle.

The above estimates of nutrient intakeassume that the whole general ration isconsumed by the recipient and there areminimal losses with food preparation.However in Wajir, food preferences andpreparation methods would have furtherreduced the intake of both vitamin C andthiamine.

Being water soluble, vitamin C is susceptibleto destruction by heat. Much of the smallamounts provided by the pulses in the generalration would therefore have been lost incooking. Recipients were also wary ofconsuming pulses complaining ofgastrointestinal problems.

The people of Wajir are unfamiliar withmaize as a food and are unsure of how best toprepare it. Thiamine intake from the maizeration would have been reduced for a numberof reasons:

• the practice of dehusking or milling themaize (most of the thiamine resides in theouter layers of the grain)

• loss in cooking (both thiamine and vitaminC are water-soluble)

• the widespread practice of drinking largeamounts of tea (the tannin in tea is athiamine antagonist and interferes with theabsorption and digestion of thiamine5)

• lack of vitamin C in the diet (Vitamin C,when consumed together with thiamine,increases thiamine bio-availability)

• A preference for tea meant that manyhouseholds exchanged some of their rationfor tea or sugar (3 kg of maize wastypically exchanged for 250g of sugar).

There is no doubt that most of the symptomsreported and observed were attributable toscurvy. Outbreaks of scurvy have occurredregularly in similar populations in the Hornof Africa6.

Reaction to findings

There was some scepticism about an outbreakof thiamine deficiency as in recent historyoutbreaks of beriberi have been limitedlargely to rice eating populations7. Yetthiamine deficiency has occurred on someoccasions in non-rice eating populations andgiven the extremely limited diet over severalmonths it could not be ruled out in Wajir. Thelevel of uncertainty meant that questions wereraised about whether this was a morecomplex picture of multiple micronutrientdeficiencies.

It was time to call in the experts to confirmthe diagnosis, develop case definitions,determine the public health significance ofthe outbreak and advise on appropriatetreatment and control of the outbreak.

The Response

While CDC (Centre for Disease Control)were initially considered for the assessment,concerns around an onslaught of technicalteams and the need to allow national teams togain experience led to the Ministry of Health(MoH) combining with the African Medicaland Education Research Foundation(AMREF) to field an assessment team at theend of September. CDC offered support toAMREF if needed.

This assessment involved extensiveinvestigation of 59 people who showedsymptoms of micronutrient deficiency. Bloodand urine samples were taken formicronutrient analysis. Initial impressions ofthe team based on clinical examination wereof a multiple vitamin deficiency syndrome -predominantly vitamin C and B-complexdeficiency. However, the symptom profile hadchanged significantly since the initial rapidassessment by the Ministry of Health andSC(UK) team. The sensory changesassociated with dry beriberi were no longerevident and the team attributed this toimprovements resulting from the introductionof a general food ration and blanketsupplementary feeding.

Because of the complexity of the presentationof symptoms, case definitions for specificdeficiencies were not possible. A broadercase definition of “ascending or descending

pain of the lower limbs (joints and ormuscles) and difficulty walking within thelast 3-5 months” was used by the team. Anassessment of prevalence based on this casedefinition was not undertaken. This casedefinition was used to identify people withpossible micronutrient deficiency disease in anutrition survey conducted by MoH andSC(UK) in the north and west of Wajir inOctober. Out of 3380 people interviewed 27cases were identified, the majority of whichwere in the west of Wajir. The low prevalenceof 0.8% indicates that the outbreak was smalland localised.

Recommendations

Recommendations by the MoH/AMREF teamincluded:

• house to house vitamin supplementation • an increase in the general food ration • GFD should include a fortified blended

cereal.

These recommendations were not circulatedwidely and the Ministry of Health was notpro-active in advocating for theirimplementation. Unfortunately the blood andurine samples were not analysed, probablybecause of a lack of technical capacity, andno confirmation of diagnosis of specificdeficiencies has been made.

Response taken

Save the Children (UK) responded to theinitial rapid assessment by:

• recommending an increase in the generalfood ration

• inclusion of a fortified blended cereal intothe ration

• grinding of the maize prior to distribution • treatment of those affected with vitamin

supplements • Admitting anyone presenting with

symptoms into the SC(UK)/MoH targetedSFP. They would then receive a weeklyration of fortified CSB.

SC(UK) were successful in securing adonation of thiamine tablets and negotiatedwith WFP to grind the maize as well asconsulting USAID to ensure CSB wasfortified. Logistical problems meant that the

DIA

NN

E S

TE

VE

NS

5 WHO, Thiaminedeficiency and itsprevention and controlin major emergencies,1999

6 WHO, Scurvy and itsprevention and controlin major emergencies,1999

7 WHO, Thiaminedeficiency and itprevention and controlin major emergencies,1999

17

Field Article

Symptoms associated with scurvy and dry beriberi

Scurvy (vitamin C deficiency) Beriberi (thiamine deficiency)

Weakness Weakness

Weight loss Weight loss

Failure to stand from squatting position Failure to stand from squatting position

Peripheral oedema Peripheral oedema

Pain in muscles/joints in legs Paralysis of the extremities

Swollen joints Reduced knee jerk and other reflexes

Dry rough skin Loss of sensation (stocking and glove)

Swollen bleeding gums Foot drop

Shortness of breath Side used affected first

Follicular hyperkeratosis Ascending symptoms

Haemorrhagic manifestations

Anaemia

Estimated composition of diets obtained from food aid per person per day

Month Diet Energy Protein Thiamine Vitamin CKcal %RDA* gm %RDA mg%RDA mg%RDA

March Maize only 187 9 5 9 0.2 22 0 0

April Maize only 187 9 5 9 0.2 22 0 0

May Maize only 187 9 5 9 0.2 22 0 0

June Maize only 730 35 19 33 0.8 89 0 0

July Maize + pulses + oil 1795 85 53 91 2.1 230 1.4 5

August Maize + pulses + oil 1339 64 37 64 1.5 167 1 5

September Maize + pulses + 2015 96 63 108 1.2 133 52 185(1st half of month) oil + fortified CSB

September Maize + pulses + oil 1365 65 42 72 1.0 111 1 4(2nd half of month) (CSB finished)

*% RDA is based on daily mean population requirements of 2100 kcal, 58 gm protein, 0.9 mg of thiamine and 28 mg ofvitamin C (WHO, 1997).

DIA

NN

E S

TE

VE

NS

thiamine did not arrive until well after the symptomsof beriberi resolved. To this day the general foodration has not been increased, the maize has not beenground and CSB has not been added to the generalration. It is fair to say that problems in the foodpipeline and the extent of the food aid requirementsacross the country rather than a disinterest by WFPwas the reason nothing was done. Fortified CSB didarrive in the country and because of the outbreak of

vitamin deficiency, Wajir was one of the districtstargeted to benefit from the CSB which waschannelled into blanket supplementary feedingprogrammes rather than the general ration. At thetime of writing the blended food pipeline was onceagain in jeopardy.Despite the confusion in the diagnosis, littleunderstanding of the extent and public healthsignificance of the outbreak and both late and

inadequate response, those affected improved simplyby providing them with a nutritionally balanced dietin the form of a fortified cereal blend. Nothing moreneeded to be done.

Lessons

Micronutrient deficiencies in emergency situationsmay well appear as a complex picture of multipledeficiencies. Deficiencies of one nutrient are unlikelyto occur in isolation. This complicates assessmentand looking for specific signs and symptoms canlead to delays in arriving at a firm diagnosis. Adiagnosis and case definition (possibly coveringmultiple deficiencies) are required to determine theextent and public health significance of the problem.This will help determine and advocate for the mostappropriate public health intervention.

Assessment and diagnosis of multiple micronutrientdeficiencies is a specialised field and requires theinput from experts to arrive at a rapid assessment andresponse. Most field personnel are unlikely torecognise that a deficiency exists in the early stagesof presentation. Diagnosis by biochemical analysisrequires the technical know-how and resources foundonly in specialised laboratories. There may thereforebe a tension between bringing in outside expertiseand utilising and strengthening local professionalcapacity. We need the experts but must ensure thatthey work with governments and leave some capacitybehind when they leave.

Nutritional surveys are a common assessment toolused in emergencies and yet generally they do notgive enough attention to the assessment ofmicronutrient deficiencies. By training fieldpersonnel in the signs and symptoms ofmicronutrient deficiency diseases (by including a fewquestions in the survey to help identify the onset ofdeficiencies) and through actively seeking cases,nutritional assessments could be better used toidentify that a problem exists.

Prevention of deficiency outbreaks

Micronutrient deficiencies can be easily prevented bythe provision of a balanced diet and yet outbreaks ofdeficiency diseases have regularly occurred inrefugee populations dependent on food aid. Years ofexperience and expert consultation over the past twodecades have led to several initiatives to reduce thelikelihood of micronutrient deficiency outbreaksoccurring during emergency programmes. Perhapsthe most significant initiative has been theintroduction of a stipulation in the WFP/UNHCRGuidelines for estimating food and nutritional needsin emergencies (1997) whereby a fortified blendedcereal should be included in the ration of all food aiddependent populations unless other appropriatecommodities can be provided.

However, in the case of Wajir, food aid arrived toolate and when it did arrive, the GFR did not meet thenutritional needs of the population. It appears thatthere was insufficient awareness of the risks ofmicronutrient deficiency disease in populationsdependent on food aid.

We recommend that key humanitarian agenciesshould, with the support of the RNIS monitoringsystem8, take steps to raise awareness among theirstaff of the important risk of micronutrientdeficiencies and better co-ordinate food aid to ensurethat it is prompt, adequate and appropriate.

There is no excuse for what happened in Wajir. Theproblem is understood and the solution is simple.Outbreaks of micronutrient deficiency disease infood aid dependent populations should be a thing ofthe past and not of the 21st century.

8 RNIS, ACC/Sub-Committee on Nutrition (V222), 20, avenueAppia, 1211 Geneva 27, Switzerland. Email: accscn@who.ch

18

Post Scripts

WFP Kenya would like toaddress some of thepoints made in the article

entitled, “Outbreak of micronutrientdeficiency disease: Did we respondappropriately?” by Dianne Stevenset al. of Save the Children (UK). Wedo not dispute the fact that anoutbreak of “micronutrientdeficiency disease” did occur.However, we would like tochallenge some of the informationabout chronology, decision-makingand actions taken by WFP and ourpartners in responding to theemergency in Wajir.

Contrary to statements in the article,there were several food securityfield assessments covering WajirDistrict between the beginning of2000 and January 2001. Food aidneeds for the people of WajirDistrict have been based upon theresults of these assessments andmonthly monitoring informationfrom the Kenya Food SecurityCoordination System (KFSCS)1,which included the extensive datacollected monthly by the Arid LandsNatural Resource ManagementProgramme (ALRMP) in Wajir. Alsocontrary to the information in thearticle, EMOP activities in Wajirbegan in June 2000 because it wasonly at that point, after the failure ofthe long rains, that the KFSCS andOxfam (GB), the current leadagency for the EMOP in Wajir,agreed that the situation was severeenough to warrant general food aiddistributions, not because of slowdonor response.

It should also be noted that fromJune 2000, it was determined thatvulnerable populations in Wajirneeded a 100 percent food aid ration(2,100 Kcals/per day) composed ofmaize, pulses and oil. Unfortunately,due to late donations, our pipelinefor all commodities and particularlypulses and oil was not adequate toensure that planned rations could bedelivered. Rations for differentcommodities therefore had to bereduced during some months toensure that other needy populationsas well as those in Wajir receivedadequate food. However,populations in Wajir District havebeen considered among the mostvulnerable in Kenya and, therefore,

have always received the largestpossible rations of all commoditieswhile under the EMOP. It shouldalso be noted that as the foodsecurity situation in Wajir worsened,due to the deepening drought afterthe poor 2000 long rains season(April-June), the percentage of thepopulation targeted for food aid wasincreased substantially from justover 47 percent in June 2000 to 80percent in August to 93 percent inJanuary 2001.

Regarding supplementary feedingdistributions, it should be noted thataccording to UNICEF/Kenya, Wajirwas one of the first districts toreceive UNIMIX in August 2000.Vulnerable groups receivedsubsequent distributions of acombination of UNIMIX and CSBin October and November/Decemberand since November/December(when sufficient quantities of CSBunder the EMOP arrived in country),CSB has been distributed as part ofthe general ration to householdshaving under fives and/or pregnantand lactating women. As illustratedby numerous documents, Health andNutrition Sector Group meetingminutes and discussions, there wasand is a great deal of awarenessregarding the need to address therisk of micronutrient deficiency.

While the possibility of WFPgrinding food aid maize forbeneficiaries was discussed, WFPnever agreed to this propositionbecause of its logisticalimpracticalities. Studies in a numberof districts including Wajir showthat beneficiaries generally havetheir maize ground in exchange for asmall portion of the resulting maizemeal.

In conclusion, given the weakness ofour food pipeline during the period,I would argue that the planning,decision making and actions takenby WFP and our partners have dealtas effectively as possible under thecircumstances with themicronutrient problem. Indicationsat this point are that with moresupplementary food having reachedWajir over the last few months, themicronutrient situation hassignificantly improved.

Oxfam Great Britain has beenworking in Kenya since the1960s, and in Wajir District

since the 1980s, implementing reliefand long-term developmentprogrammes.

Oxfam Great Britain has been thelead agency for food distribution inWajir since June 2000. Oxfam GBalso implements drought mitigationand response activities across Kenyain various sectors, including water,livestock and nutrition. Whileagreeing with the main points of theSC(UK) article on Wajir, I do thinkthat there is a need to place theproblem in perspective.

A serious drought has been affectingKenya since 1999. Manycommunities describe the drought asthe worst they can remember.Emergency food aid operationsbegan in some districts by December1999. The joint World FoodProgramme - Government of Kenyaoperation (EMOP) initially targeted1.7 million people in 18 districtsfrom March to June 2000.Distributions began in the four worstaffected districts (Turkana, Moyale,Mandera and Marsabit) inMarch/April, and by June twelvedistricts, including Wajir, werereceiving food. With the failure oflong rains in April, the situationworsened and the EMOP expandedto cover 2.2 million people in 19districts from June - December2000.

Decisions on where and how tointervene were taken based on thebest available local information,including reports from thecoordination system, assessments,local situation reports and earlywarning bulletins. Throughout thisprocess attempts were made to usestandard criteria for interventionacross districts. Many of thedistricts, Wajir in particular, havebeen plagued by a series of climaticemergencies in the past decade, andsuffer from very high levels ofchronic poverty. In this context, itwas very challenging to try todistinguish between the effects ofchronic vulnerability and droughtshock. Seasonal factors are alsocomplex - in a normal dry season inNorth-eastern Kenya, childmalnutrition rates often peak at a

level that it is considered seriousaccording to recognised cut-offpoints.

The short rains due in October 2000were poor again. In this light, arevision to the EMOP was proposedto extend the life and scope of theEMOP. It is now likely to run at anexpanded level (up to 4.4 millionbeneficiaries) until at least June2001.

Alongside the EMOP, the school-feeding programme has beenexpanded. In addition to generalration distribution, supplementaryfeeding was planned for all affecteddistricts and implemented asresource constraints allowed, as wellas interventions in other sectors suchas health, water, livestock andeducation.

This operation represents anenormous investment of resources,as well as initiating new ways ofworking at every level. National anddistrict level coordination structureshave been used to manage a majoremergency for the first time.1 Thesecoordination mechanisms haveattempted to build on learning fromprevious interventions by taking onmajor initiatives such as foodsecurity assessment andgeographical targeting. In theimplementation of the programme,standardised approaches have beenadopted such as community basedtargeting and distribution.

The way of working has been a stepforward for Kenya. The single-delivery system has meant thatresources have been prioritisedaccording to need and deliveredreasonably consistently.

However, resources are neverenough, and slow arrival of food aiddid make this operation lesseffective than it could have been.Oxfam GB had planned for blanketdistributions of Unimix tovulnerable groups in Wajir in June2000, but was not able to implementthis until August due to resourceconstraints. Nevertheless, given theseriousness of the drought, the factthat the humanitarian situation is notmuch worse is a reflection of justhow much has been learnt from thepast.

Kenya drought emergency operation 1999 - 2001

Response to SCF Wajir Article

By Emma Naylor, humanitarian programme coordinator, Oxfam GB Kenya Programme

Postscript/Responseto SCF Wajir article

by David Fletcher, Deputy Country Director,WFP/Kenya

1 as highlighted in the article by Robin Wheeler “Developmentof Kenya Food Security Coordination System (KFSCS)”

Post Scripts

19

Field Article

Rapid impact on malnutritionthrough a multi-faceted programmein Wolayita, Southern Ethiopia

By Kate Sadler

Kate Sadler undertook her MSc inPublic Health and Nutrition atLSHTM. She has spent over 3

years working for ConcernWorldwide in Burundi, Rwanda

and Ethiopia. Currently inEthiopia, she is supportingongoing emergency feeding

programmes as well asdeveloping community health and

nutrition programmes for thepost-emergency recovery phase.

Background

Damot Woyde Woreda is located in North Omo Zone,Southern Nations, Nationalities and Peoples RegionalGovernment (SNNPRG). It is 385 km South of AddisAbaba. The Woreda is characterised by a rugged,mountainous topography with valleys and gorges and isdivided into 48 kebeles. It has a population of 172,877(Woreda Council 2000) and has a high population density,with between 125 - 742 people per square kilometre in themid- and highland areas.

The region of Wolayita has been identified for a number ofyears as a food insecure area. This is caused by acombination of factors - high population density withhigher than average family size (7-8 per household), smallland holdings and serious soil erosion. Furthermore, areliance on rain fed agriculture by the majority of farmersin an area which receives erratic rainfall, adds to an alreadyfragile situation.

Concern Worldwide has worked in Damot Woyde since1984, both in emergency relief and integrated ruraldevelopment, although left the area in 1998 in line withgovernment policy. In 2000 on the request of regionalauthorities, Concern once again began emergencyassessments to identify needs arising from the most recentdrought.

Nutrition and Food Security: April 2000.

Following three successive poor harvests including thecomplete failure of the main Belge harvest (Jun/Jul 99),acute food insecurity was once again becoming a reality inDamot Woyde. In April 2000 the Belge rain was already 2months late and the prospect for a harvest looked poor. Thesweet potato crop, which is traditionally used to mitigate

the effects of the hungry season, had failed for the thirdconsecutive season and maize, usually harvested green inJune/July, had not been planted at all. Although much ofthe land had been tilled there was nothing visibly planted,as the soil was completely dry. Even the coffee trees wereburnt from the extreme heat. Most of the ensette1 in thefields seemed to be harvested. In normal circumstancesonly matured ensette is harvested when it has beengrowing for 6-7 years. The early harvest of this cropreduces further the value of an already nutritionally poorfood. People reported that they were on one meal a dayand this was mainly ensette. They were very worried thattheir children were also only getting ensette to eat. Inaddition, the availability of water and pasture for livestockwas severely reduced. Many households reported recentanimal deaths and that they were unable to sell livestock asdemand was so low.

A two-stage 30 cluster nutrition survey conducted byConcern between the 14th and 19th April 2000 identifiedworrying levels of both global and severe acutemalnutrition at 25.6% (<-2 z-score and/or oedema) and4.3% (<-3 z-score and/or oedema) respectively.

Response

In order to address this situation Concern becameoperational with the following objectives:

Programme Goal

To prevent the deterioration of the nutritional status of theunder 5 population and pregnant/lactating mothers inDamot Woyde Woreda and to contribute towards thenutritional recovery of any in this target group found to bemoderately or severely malnourished.

1 Ensette is a root crop not dissimilar to cassavawhich is widely grown in Wolayita andcommonly known as false banana.

Supplementary FeedingCentre, Damot Weyde,

Ethiopia

PIETERNELLA PIETERSE/CONCERN

1. To treat current high levels ofmalnutrition.

By the middle of May Concern had opened 3therapeutic feeding centres which gave 24-hournutritional and medical care2 for all severelymalnourished children. A team of 5 experiencedexpatriates (including 3 nurses, 1 nutritionist and 1paediatrician) and approximately 320 national staff,many of whom had worked for Concern previously,ran the centres. By the end of September 874children had been treated with the results presented intable 1.

Targeted supplementary feeding was startedsimultaneously for all moderately malnourishedchildren less than 5 years old and pregnant andlactating mothers. This involved a fortnightly mobiledistribution to 10 separate decentralised sites acrossthe Woreda. Treatment included a 3.5kg ration ofCSB (approximately 900 kcal/beneficiary/day) aswell as basic medicines including vitamin A, folicacid and mebendazole.

By the end of September 5,407 children and 2,272pregnant/lactating women3 had passed through orwere still being treated in this programme. Monthlymonitoring statistics gave the results shown in table 2.

The programme for pregnant and lactating womenwas not evaluated. Criteria for admission was MUAC< 210 mm and discharge was at 230 mm. Thecombination of these two criteria resulted in a slowrecovery rate and high non-recovery rate, i.e. manywomen were discharged after 3 months or when thebaby reached 6 months without the mother reachingthe target MUAC.

2. To increase food available to the mostvulnerable households.

In January 2000 official figures released by the

Government of Ethiopia indicated that 54,000 peoplein Damot Woyde Woreda were in need of monthlyfood assistance. This figure was said to be risingrapidly and by April of the same year was generallythought to be an under-estimation. For many reasons4

the Woreda Administration did not have the capacitynor the resources to respond to the food needs in thearea. Only 325 tonnes of grain had been delivered toDamot Woyde by April 2000 (enough only for a oneoff distribution to 26,000 people) and much of thisremained in warehouses.

In order for Concern’s targeted feeding programmesto be effective, to prevent many more peoplebecoming malnourished and to minimise re-admissions to targeted feeding programmes, a generalfood ration was essential for those in need. Concernassisted the Woreda Council with this objective by:

• Local purchase5 and distribution of general food(12.5kg of grain per person per month)6 to 54,000of the most vulnerable people in the Woreda forfour months (June to September). Beneficiary listswere drawn up by the Woreda authorities andsubsequently verified by a Concern team to ensureall recipients fulfilled the criteria for vulnerability

• Providing a small quantity of fuel and repairing theWoreda truck.

• Providing training on food aid targeting to theWoreda Council and assisting in post distributionmonitoring.

3. To improve prospects for household foodsecurity.

Some of the most important seeds required byfarmers, including teff, sweet potato, wheat, maizeand beans, were distributed to 11,000 of the mostvulnerable households. Seeds were purchased locally.This enabled many impoverished farmers to plant inJuly for the Meher season.

Co-ordination & Advocacy

In addition to identifying the acute need forintervention in this area, the survey results gaveConcern the necessary information to highlight thearea of Wolayita as one that required urgent attention.Up until this time Wolayita had not been considered apriority area by either the Government of Ethiopia orby international donors. Whilst getting programmesestablished Concern lobbied at the federal level formore food aid for Wolayita and for a more balancedration. This resulted in Damot Woyde and otherWoredas in the area being included among the firstpriority Woredas on WFP’s ‘Priority Areas for Pre-Positioning’ of general food and in an increase in thenumber of people listed as requiring food assistance.

A Wolayita region co-ordination group was alsoinitiated which, as well as acting as a forum forinformation exchange also added weight to thelobbying at federal and donor level. This grouphighlighted to other NGOs, areas in Wolayita wherethere was little information on nutrition and foodsecurity status. This resulted in OXFAM GB andMSF Spain becoming involved in the neighbouringWoreda of Bolosso Sore and MSF Switzerlandstarting emergency programmes in Damot GaleWoreda.

Nutrition and Food Security: July & October2000 - measuring programme impact.

20

Field Article

Acute Malnutrition Measured by Weight for Height

April 2000 July 2000 Oct 20006 - 59 Months (C. I.) (C. I.) (C. I.)

Global Malnutrition 25.6% 6.4% 7.2%Z score < -2 and/or oedema (22.9-28.5) (4.3-9.2) (5.0-10.1)

Severe Malnutrition 4.3% 1.0% 1.0%Z score < -3 and/or oedema (3.2-5.9) (0.3-2.6) (0.3-2.6)

Month June July August Sept TFC Averaged across 3 centres Target*

Recovery rate (as % of exits) 91 96 99 100 > 75

Mortality rate (as % of exits) 3 4 1 0 < 10

Default rate (as % of exits) 6 0 0 0 < 15

Average weight gain (g/kg/d) Marasmic - ** - 14.6 16.0 > 8

Average weight gain (g/kg/d) Kwashiorkor - - 10.7 8.2 > 8

* Humanitarian Charter and Minimum Standards in Disaster Response. (Sphere, 2000)** Reporting did not include this information at the start of the programme.

Table 1

Month June * July Aug Sept SFP Target **

Averaged across 10 centres(for all children < 5 years)

Recovery rate (as % of exits) 48 64 88 84 > 70

Default rate (as % of exits) 23 36 12 16 < 15

Average length of stay (weeks) - 10.5 10.8 12.8 -

* At this stage many direct referrals to the TFCs were being included in SFCstatistics. These cases account for the remaining 29% of exits. Additionally asignificant number of children found to be “cheaters” e.g. registered twice atthe same SFP site, were being counted as defaulters - some centres thereforehad relatively high default rates in June and July.** Concern Worldwide “Nutrition in Emergencies” 1996

Table 2

South Wollo, Ethiopia

DE

RM

OT

TAT

LOW

/ C

ON

CE

RN

A second survey was undertaken three months afterthe first. This survey identified a dramaticimprovement in the rate of both global and acutemalnutrition in Damot Woyde Woreda. The thirdsurvey in October showed a stabilisation in the rate ofmalnutrition as well as identifying a relatively morepositive food security environment. By October,malnutrition accounted for only 6% of all deathsrecorded during the survey. This compared with 32%in July. The major causes of death had changed frommalnutrition and malaria to malaria andcough/respiratory disease (43% and 29% of all deathsrespectively).

This improvement in the nutritional status of thepopulation was generally thought to be attributed totwo main factors: Concern’s nutrition interventionsand improved food security.

Nutrition Intervention

Since April 2000 Concern had implementedtherapeutic and supplementary feeding, communityoutreach in all kebeles to identify and refer all at riskindividuals and general food distribution to 54,000 ofthe most needy individuals.

By October, Concern had closed the last of itstherapeutic feeding centres and children identified asseverely malnourished are now referred to thenutritional rehabilitation unit in nearby Sodo hospital.Concern’s supplementary feeding programme isongoing7 although the proportion of those dischargedwho fully recovered is increasing. This is thought toreflect the overall improvement in the food securitysituation of the Woreda.

Improved Food Security

With the arrival of rain in May animal health visiblyimproved in the area and by late June manyhouseholds began harvesting small quantities ofbeans and kale from their fields. In October postdistribution monitoring indicated that the majority ofthe seed distributed had been planted and wasmaturing successfully. In addition, most householdswere eating two meals a day of maize or wheat,beans, cabbage and coffee and in some cases sweetpotato, milk and sorghum. For the majority, the mainsource of food was the market with income comingfrom daily labour, credit and the sale of grass,firewood and in some cases agricultural produce suchas cotton, green maize, cabbage and milk.

While a large proportion of the dramatic decline inmalnutrition between April and July was due to thearrival of rain in May and the general improvement inthe food security and animal health situation seen byJune, evidence from near-by Woredas indicates asignificant impact of the Concern intervention inWolayita. In neighbouring Bedewacho Woreda, whichdid not benefit from early assistance from an INGO,a nutrition survey in August found that malnutritionrates remained relatively high at 16.8% GAM and4.8% severe wasting.

Lessons Learnt

• The programme implemented a number of activitiessimultaneously which, as well as treating thosealready sick, attempted to address the wider foodproblem.

• Activity implementation was generally consideredto be timely - feeding began within 2 weeks of thesurvey, when food access was extremely low.

• The programme was able to use many experiencednational staff who had worked previously innutrition programmes for Concern. With relativelylittle training and supervision they were able toimplement programme protocols effectively.

• Experienced expatriates on the team enabled highquality of service provision from the start of theprogramme. This was especially true for thetherapeutic feeding centres for which the presenceof a paediatrician, a nutritionist and 3 nurses almostcertainly kept mortality rates low and recovery rateshigh throughout.

• Dissemination of information and advocacy at aregional level was extremely important to ensurethat areas in need received due attention and timelyintervention.

Admission criteria for pregnant and lactating womento the supplementary feeding programme were toogenerous resulting in a slow recovery rate and a highnon-recovery rate.

Conclusions

• The stabilisation in the rate of malnutrition is agood indication that Concern’s nutritionintervention has achieved its programme goal andthat generally short-term household food securitystatus has improved. Future nutrition and foodsecurity status however will remain fragile:

• Concern has ceased all general food distributionsand pending the end of year harvest, any futurefood distributions are the responsibility ofDPPC/WFP.

• Although the majority of the population arecurrently harvesting, many farmers are having touse a large proportion of their harvest to recoverfrom the previous food crisis i.e. pay off debt,purchase agricultural seeds and tools.

• Household diet and sources of income remainlimited, especially in the poorest households.

• The health, especially vaccination status of much ofthe population remains very poor.

Future Priorities

• Supplementary feeding should continue in orderthat the large number of beneficiaries who remainin the programme can reach their target weight.Programme phase-out should begin in Jan 2001with finalisation of the hand-over strategy to theMinistry of Health.

• The nutritional rehabilitation unit in Sodo Hospitalshould continue to be the referral facility forseverely malnourished children from the Woreda.This unit would benefit from continual support inthe form of monitoring visits and trainingopportunities.

• Continue food security monitoring and implement afourth survey in 6 months time to ensure thatnutritional status has remained stable.

• In order to sustain nutritional recovery acommunity health and nutrition programme,developed in conjunction with the Woreda Ministryof Health, is now a priority. As well as addressingimmediate needs such as low vaccination coverageand poor health centre capacity it should begin todevelop strategies which will improve longer-termfood and health security.

• Criteria for admission, monitoring and discharge ofpregnant and lactating mothers should be re-evaluated and developed for this population group.Further research is required in this field.

Concern would like to acknowledge OFDA, Ireland Aid, Fyffesand EthiopiaAid who have generously supported the aboveprogrammes.

21

Field Article

0

500

1000

1500

2000

2500

3000

OctSepAugJulJunMay

Month

No.

of ad

mission

s

Total admissions (<5yrs):SFP Damot Woyde

2 All care administered followed standard WHO/MSF/Concernprotocols.

3 All pregnant women in the third trimester were admitted tothe SFP. This was difficult to verify as many were notreceiving antenatal care and did not have a card withestimated time of delivery recorded. Many of the womenwere admitted based on appearing to be in the 3rdtrimester.

4 A country-wide shortage of grain: even though many donorshad pledged grain for Ethiopia by April 2000, a gap of atleast three months was anticipated before these pledgesreached the required destinations. Lack of fuel andtransport at Woreda level for grain distribution: DamotWoyde Woreda Council had very little capacity to distributegrain once it arrived in Woreda warehouses.

5 Shashemane only 2 hours to the north remained a surplusproducing area where food was available for local purchase- this contrast in the food security of neighbouring areas iscommon across Ethiopia and is an important issue to beconsidered when discussing famine preparedness andprevention.

6 This ration complied with the National Policy for generalfood distribution.

7 Total beneficiaries at the end of October: 2769 children and1648 mothers

DE

RM

OT

TAT

LOW

/ C

ON

CE

RN

South Wollo, Ethiopia

22

Agency Profile

Most people have heard of the Centre forDisease Control and Prevention - known asCDC. Based in Atlanta, Georgia, CDC is

part of the Department of Health and HumanServices in the US government and deals withmatters of public health. CDC’s work mainly involvespublic health in the US (more than 95% of CDCfunding). The International Emergency and RefugeeHealth Branch (IERHB) within the CDC is less of ahousehold name. Formed within the last three years,this branch has now become the formal centre ofCDC humanitarian emergency activities overseas.The focal person for IERHB nutrition activitieswithin IERHB is Bradley Woodruff. Up until 1996 heworked in the CDC Hepatitis Branch but joined theunit dealing with humanitarian emergencies (a pre-cursor to IERHB) in 1996. Field Exchangeinterviewed Bradley by phone.

Bradley recalled that CDC’s involvement inemergency work overseas began with the Biafrancrisis at the end of the 1960s. This introduction tointernational emergency work was marked by thetragic death of a CDC staff member who was killedin a plane crash while on mission. In the late 1970sCDC sent various staff to assist with epidemiologicalwork in the Kmer refugee camps in Thailand. Thefirst staff member to be employed specifically forfull-time work in humanitarian emergencies wasMike Toole in the mid 1980s. Mike’s extensiveexperience of refugee and other emergencyprogrammes made this appointment a coup for CDC.Mike worked alone until the early 1990s. Theappointment of additional full-time ‘humanitarianemergency’ staff resulted in the coalescing of theiractivities into a unit (1994). Staff from this unitassisted UNHCR and UNICEF in their responses tothe refugee crisis in Zaire following the genocide inRwanda. CDC staff realised that NGOs wererelatively ill-prepared to respond to such a largeemergency. As a result, OFDA funded training ofstaff from US PVOs (US NGOs). CDC were involvedin writing curriculum and evaluating the pilottraining. The formal formation of a branch withinCDC dealing with humanitarian emergencies -IERHB, only occurred in 1998

IERHB now has 9 full-time staff including 5 medicalepidemiologists, a statistician/epidemiologist, apublic health assistant, and administrative support.The branch has access to all CDC staff which ensureswide-ranging technical expertise and laboratorysupport.

Focus of activities

The main areas of IERHB activity are:

• Emergency response• Training and Capacity Development• Operational Research• Programme Evaluation• Information Dissemination

Bradley explained that IERHB works withorganisations that need epidemiological or publichealth expertise and provides technical assistanceupon request. Collaborating organisations includebranches of the US government (OFDA, USAIDetc.), UN agencies, international and local NGOs andgovernments. Most of the NGOs are US NGOs “asEuropean NGOs tend to have more ‘in-house’epidemiological expertise” - although Bradley feltthat this was changing.

The types of work undertaken by IERHB include

• epidemiological surveillance• rapid health assessment• health and nutrition assessment surveys• outbreak investigations• disease control programmes • training in public health and epidemiology• evaluation of health services

IERHB and nutrition

All IERHB staff have nutritional epidemiologicalexpertise and can undertake or advise on nutritionalassessments. Staff tend to work overseas for 4-12week periods. Bradley acknowledged that “thismakes it difficult to get involved in long termproblem solving”.

Bradley explained that IERHB do not get veryinvolved in assessing food security leavingapproaches like household food economy andlivelihood analysis to other agencies with greaterexpertise. He did however admit to a sense withinIERHB that there is a need to start thinking abouthow to better integrate food security andanthropometric assessment information.

The branch is also asked to undertakeepidemiological work on micro-nutrient deficiencyoutbreaks. They were asked by UNHCR and WFP toinvestigate the riboflavin deficiency outbreakamongst the Bhutanese refugees. The excellentlaboratory back-up of CDC makes IERHB ideal forthis type of work.

Bradley affirmed that being involved in nutritionalsurveys and assessments can place IERHB inpolitically sensitive situations as “results may notalways be what agencies want to hear”. However,“CDC/IERHB’s reputation and track-record is suchthat most agencies trust the objectivity of findings”.

IERHB is a WHO collaborating centre for emergencypreparedness and response which means that WHOcan theoretically call them up at any time for help.IERHB also assist in training staff from the USgovernment, UN agencies, INGOs, universities, andministries of health in foreign governments. Staff alsoattend scientific meetings and assist in curriculumdesign. In the nutrition field, training is limited toepidemiology and assessment. IERHB are notinvolved on the nutritional intervention side.

Research activities of IERHB

A number of nutrition related research programmeshave been completed by IERHB. One study inTanzanian refugee camps found that iron dosagesthree times a week were effective in treatingmoderate and severe anaemia.

There has also been research into optimalanthropometric measures of malnutrition inadolescents. This research came about following thereported high levels of severe anaemia andmalnutrition in adolescents in Kakuma refugee camp.A study in Kakuma and three Dadaab camps inKenya found that, using WHO anthropometric

criteria, prevalence of wasting amongst adolescentswas very high whereas under five wasting andmortality levels were low. At the same time foodsecurity in the camps appeared to be adequate. Therewere similar findings amongst Bhutanese refugees.This led IERHB to question the applicability of theWHO guidelines on anthropometric assessment ofadolescents and to IERHB's involvement in the recentSCN publication on optimal ways to measurenutritional status of adolescents (see this edition ofField Exchange).

Another study completed by IERHB has involvedlooking at outcome indicators (mortality andmorbidity) in 52 camps in stable situations (afteremergency related mortality has stabilised) in relationto nutrition and health indicators. The aim of thisstudy is to determine which variables lead to bestoutcome. Results are soon to be published.

On-going research in the branch includes developingfield-friendly techniques for measuring iron, vitaminA and iodine status. A recent survey conducted byIERHB found a 4% prevalence of bitot spots amongstadolescents but when blood samples were taken backto CDC prevalence of low serum vitamin A was over30%. Bradley felt that this showed how important itis to develop field techniques for serum assays asclinical diagnosis can be so problematic. “Basically,we need to develop something like a haemocue butfor Vitamin A.”

IERHB are also hoping to conduct research intostandardising case definitions of scurvy. As many asthree case definitions have been used by the sameagency. Bradley is hoping for an opportunity toconduct simultaneous clinical and biochemicalassessment.

IERHB wish to expand their R & E activities and arecurrently talking with Epicentre in France and twoUS universities about potential collaboration.

It appears that other parts of CDC may be moresusceptible to political pressures than IERHB. Forexample, CDC efforts to conduct research into needleexchange programmes to prevent spread of HIV inthe US and epidemiological studies of theeffectiveness of gun control programmes wereresisted in the past for political reasons. Bradleycould only think of two reasons why IERHBactivities might be curtailed: conflict with US foreignpolicy and security concerns. As examples, “Travel toIran was not allowed due to foreign policy towardsIran while work in Burundi has been disallowed inthe past for security reasons”. However, the fact thatCDC’s main constituency are state healthdepartments, which have a great influence on CDC’soverall operation, means that CDC generally have afair degree of autonomy over what they do whileIERHB have even less political interference becausetheir work is based overseas and therefore rarelyposes a threat to political interests. CDC has no legalregulatory authority, either within the US or overseas.

Bradley believes that there is still limitedunderstanding internationally of CDC’s work and that“CDC provides a unique centralised repository ofepidemiological expertise”. Only a few othercountries, such as Canada and France, have similarcentres and these centres may not have the samedegree of involvement in overseas work. Bradley alsobelieves that increasing awareness of CDC and itswork is stimulating other countries to think aboutdeveloping similar in-house governmentepidemiological expertise and that this can only be agood thing.

International Emergency and RefugeeHealth Branch in CDCBy Jeremy Shoham

Name International Emergency and Refugee

Health Branch (IERHB), CDC

Address 4770 Buford Highway, Atlanta,

Georgia 30341

Telephone +1 (770) 488-3526

Fax +1 (770) 488-7829

Email Bwoodruff@cdc.gov

Internet http://www.cdc.gov/nceh/ierh/default.htm

Year formed 1998

Director Acting Director: Bradley A. Woodruff

HQ staff 9

23

Field Article

In the last 500 years East-Timor has beeninvaded by the Portuguese, Japanese andIndonesians. The final period of colonisation

involved a genocidal campaign of terrororchestrated by Indonesia. The west turned ablind eye to the invasion and repression in East-Timor. Out of a population of approximatelyone million an estimated 250,000 people weremurdered over a twenty-five year period.

Surharto’s regime did little to develop East-Timor, continuing the Portuguese policy ofexploitation. The regime built roads to helpplunder the country of its teak and coffee. In the80’s large deposits of oil were found in theTimor Gap, the stretch of water that separatesEast-Timor from Australia. This attracted theattention of a circling pack of western interests.

In late 1999, to prevent further atrocities byIndonesian backed militias and assist the peopleof East-Timor in defending the outcome of theirreferendum, in which the people of East-Timorchose independence, the UN intervenedprimarily with the use of Australianpeacekeepers.

Reconstruction begins

The money for work programme in East Timorin which I was recently involved, was fundeddirectly by the US government via USAID andas such represented a change in policy, in thatmuch of USAID’s assistance in other parts ofthe world is usually in the form of loans andtechnical aid. It was anticipated that the positivespin-offs of this project would be:

i) The promotion of the US dollar over othercurrencies that were likely to replace theIndonesian Rupiah i.e. the Australian dollar

ii) A reduced risk of inflation and resultinginstability in the economy by virtue ofintroducing a strong currency

iii) An enhanced ability for East Timor tocontinue trading by virtue of having a hardcurrency, thus providing a comparativeadvantage with their nearest trading partner i.e.Indonesia.

My own role as one of 12 UNfinance/procurement officers meant being thecontact point at district level for these funds.Our function was to collect the money,distribute it, account for it, create budgets withthe project co-ordinator, provide a narrative ofthe project and supervise the work groups withthe various project managers. The scheme wasknown locally as the ‘Temporary EmploymentProject’ or TEP’s.

The scheme was a challenge in many ways.Although similar to ‘Food for Work’ inproviding a way to stimulate reconstruction, itwas different in that it gave beneficiaries at themicro-economic level control over thedevelopment of the market, i.e. the spendingdecisions that determine the relative price ofgoods and items produced.

TEP’s started in April 2000 and were launchedby a campaign over the radio, in newspapersand on public notice boards. Therefore, whenthe work started in May 2000 there was at leastsome knowledge out in the communities, as waswitnessed by the large numbers of people thatturned up at various UN district offices lookingto join work groups.

Of course, there were questions concerning thework and how people were to be paid,

particularly with regard to payment in USDollars. We made pay-day every Saturday. Thedecision to pay on a weekly basis in our districtwas taken with local partners. It meant that:

1. There was regular reinforcement /familiarisation with the US currency.

2. We had contact with people doing the workso got to know their problems quickly (e.g. ifthere were not enough tools and supplies tocomplete the job within the time-frame).Furthermore, it helped to develop arelationship between the UN and people inEast-Timor. We became familiar with manyof the local chiefs and headmen and wereable to talk about the work at project sites. Italso meant that we were able to monitor theprogress of the work against plans that wehad submitted to US AID in Dili prior togrant allocation.

3. The money went into the community as soonas possible and did not sit in our safe. Webelieved that it was advisable to pump moneyin quickly to ensure rapid re-construction andre-establishment of trade. This did happenvisibly, with the local markets growing andattracting more traders, although it wasdifficult to measure the volume increase andto gauge the relationship of TEP’s to thisincrease.

4. Each payment meant that we held less moneyand therefore were potentially less of a target.Fortunately, no insecurity was experienced asa result of holding or distributing the money.The movement of money around to varioussites where groups were working was asecurity concern. At first people came intotown to collect their pay, but due to (a) large

Money for workin East-Timor

By Mike Parker

Mike Parker has worked in the Humanitarian Aid and Development sector for nearly ten years. Hehas worked in a number of roles ranging from working with grass roots education groups insouthern Africa in the early nineties to larger scale government health and finance programmes. Thisarticle arises from Mike’s experience in East Timor from May to November 2000.

Cash dash - The author on a cash collection flighton board of a Puma with a Russian Federationcrew and an Australian peace-keeper escort.

groups, milling around waiting to be paid and (b)the need to gain a better idea of the work that wasgoing on, we decided, where possible, to pay at thesites. This did decrease tension, allowing us to seethe work on a regular basis and therefore monitorprogress against the project plan. Occasionally, itwas necessary to hold back money, where it wasclear that no work or very little work had beendone. This never happened without discussion as towhy we were taking this action.

TEPs - The work itself

Most of the work centred around the town and thereconstruction of various community structures,which had been damaged by fighting and neglect, butdid not include UN occupied buildings - although thedistinction was sometimes blurred. A great deal ofthe work involved road maintenance and clearing themetre deep gutters essential to direct run-off awayfrom the roads so as to prevent further road erosion.Most of the roads had been left in a state of neglectby the Indonesian authorities. The local hospital wasrehabilitated, as was the health clinic in Betano. Aworkshop was opened-up and work commenced on adilapidated fish farm.

Pay differentials

Some of the workers were skilled and therefore paidat a higher rate. We also paid the supervisor at aslightly higher rate. All these rates were set byUSAID. For example, a worker received $3.21 perday, a supervisor and skilled worker $4.17 and amanager $6.00.

Women’s groups

It was important to ensure that women were includedin the scheme. They therefore had their own groups,most of which were involved in communityrehabilitation works like the health clinic in Betanoand the community centre in Same. One criticism of

the programme was the limited number of women’sgroups and the scope of their work. Of the forty or sowork groups only 5 were women’s groups.Furthermore, it seems that some of the women wouldthen hand their money over to their husbands, but wehad no real information on the distribution of thismoney and what it was spent on or what difficultiesmight have arisen.

Strengths of the programme

The US dollar stability added strength to the East-Timor economy. It allowed for a continuation of tradein favour of the East-Timorese economy as desperateIndonesian traders sought security in dollars. Withthe introduction of the dollar inflationary pressureswere experienced by those holding IndonesianRupiah. The Australian dollar, a possible alternativeto the US dollar was also experiencing problems witha 5% loss in value against the US dollar over a 6month period. Thus, those holding US dollars wereable to gain as they traded US dollars against Rupiahand the Australian dollar. But this only benefitedthose who were working and being paid in UScurrency.

The money was easier to store and handle than awarehouse of consumables and therefore needed lessresources in order to support - just myself, a coupleof armed police officers, a safety deposit box andtransport. This contrasted with a food aid programmeusing, for instance, rice or wheat which would haveto be transported along treacherous roads that wereoften impassable. Also, such foodstuffs would needcareful storage so as to prevent spoilage.

Weaknesses of the programme

Limited time for programme implementationstipulated by donors created problems of effectivemonitoring, as the project had a start date of April2000 and a finish date of September 2000. Althoughall parties had the desire to see the money ‘out there’

as soon as possible, the time-frame was a factor thatled us to centralise much of the work near the localdistrict centre. As a result, the sub-districts were lesswell served - something we rectified with subsequenttranches of money, with the sub-districts being givenpriority.

On occasions, there was nothing to buy i.e. not evenrice, due to crop failure that had in part been due tothe forced internal displacement of people around thecountry. Large areas of previously cultivated landremained unused and much of the irrigationinfrastructure was in need of substantialrehabilitation. Furthermore, not all sub-districts were‘money’ oriented, relying more on barter andsubsistence farming. In the latter stages of the TEPsthis was taken into account so that ‘food for work’schemes were established alongside TEPs in thoseareas where there was a greater need to provide basicfoodstuffs rather than cash, e.g. in Aileu, some 50kmssouth-east of Same.

Opportunities created by the programme

Savings and investments by individuals andgovernment and the development of cross-bordertrade.

Programme Threats and Concerns

i) Possible armed robbery, which although always athreat never actually occurred, probably due to thehigh degree of honesty amongst the East-Timoreseand the presence of large numbers of police andtroops to provide escorts.

ii) Misinformation concerning the dollar i.e. the ideathat the US dollar would suffer a similar fate to thatof the Portuguese Escudo which experienced a loss ofvalue that led to people’s savings being wiped-out‘overnight.’

iii) Irregular supplies of dollars - this never actuallyoccurred but was a concern.

24

Field Article

Fish market in East Timor, 2000

JACK FINUCANE / CONCERN

25

Evalutations

In September 1999, WFP and UNHCRconducted a joint evaluation of theirassistance (Protracted Relief Operation

(PRO)) to Somali and Sudanese refugeesliving in camps in Kenya. At the time of theevaluation there were approximately 120,000refugees (mostly Somali), in Dadaab, with theremaining 80,000 (75% Sudanese) inKakuma. The focus of the evaluation was theexisting PRO although the team also assessedthe impact of the long-term assistanceprovided since 1991. The main findings aresummarised in this article.

Economic Environment

The refugee programme in Kenya has for nineyears been characterised in terms of protractedrelief with little possibility of breaking themould of dependency. Regional wars haveshown no sign of abating while the forecastfor large-scale repatriation have not beenpromising with resettlement providing asolution for relatively few refugees.

Traditionally, refugee self-reliance iscontingent upon external economicopportunities, e.g. integration, trading,mobility, employment. In Kakuma andDadaab camps, enforced containment and thelack of durable solutions forced the evaluationteam to examine the extent to which aninternal economy might be viable.

General distribution

Large amounts of staff and time were involvedin supporting the distribution process,particularly in Kakuma. For security reasons,food distribution in both camps was carriedout on a bi-monthly basis. The result is thatimplementing partners utilise staff andresources exclusively for distribution to thedetriment of other programmes. In Kakuma,for instance, school attendance drops duringdistribution while other programmes andservices, e.g. shelter and social services, areundermined by the fact that transport and staffare monopolised twice a month for five days.

The solution lies in a combination of (a)increasing the capacity of the distributioncentres, (b) moving to a once-monthlydistribution, and (c) having alternative EDPstorage to reduce in-camp transport costs.

Empty food containers

WFP has used empty food containers (sacksand oil tins) in a number of innovative waysin Kakuma and Dadaab. In Dadaab, forinstance, between October 1998 and July1999, WFP distributed 778,069 sacks and210,770 tins for various purposes. The sacks(with a market value of 8-10 KSh each) weredistributed to girls in schools to encourageenrollment and regular attendance. From 1993

to 1999 girl attendance in primary schoolsrose from 1,524 to 8,295, in part attributableto this incentive programme. Sacks and tinswere also distributed within the variousincome generating and skills programmes toencourage female attendance.

The most impressive use of empty containershas been in Dadaab where WFP raised 2.52million KSh by selling them to CARE, thenusing the money to construct 33 classrooms.In addition, tins were used in constructingschool walls and latrines. In Kakuma, tinswere used for home roof construction byunaccompanied Sudanese minors.

Trade in food commodities

The general consensus among refugee andagency representatives is that self-reliance onanything more than a piecemeal basis is not aviable option for people within a closed andbarren environment. Integration as a durablesolution has not been pursued by theGovernment of Kenya, though the evaluationteam found a surprising level of economicintegration between refugees and localpopulations. In Dadaab in particular, a largenumber of Kenyans act as ‘middlemen’ fortrade in food commodities between the campsand regional towns. In Kakuma, Turkanapeople will purchase small quantities ofrations from refugees, then sell them at thelocal markets.

CARE in Dadaab and LWF in Kakuma haveencouraged skills development and incomegenerating activities, some of which have anexternal market value. In Dadaab, loans aregiven to some refugees setting up business inthe market which in turn relates to the‘export’ of food items. It is estimated that upto 20 percent of WFP food items are sold byrefugees so as to obtain other essentialcommodities (including different foods). Whatis not known, however, is the manner andscale of such trade and how this impacts uponthe refugee community as a whole. Theevaluation team believes it is necessary tohave a much clearer picture of the internaleconomy of the refugee camps and theexternal economy vis a vis Kenyan traders.

Food-for-work

The team found it useful to designate threerefugee categories based on wealth and accessto resources: (i) those with tradingopportunities, (ii) those with job opportunitiesand (iii) those with no income opportunities.It is clear that those in a relatively higherearning bracket are few.2 A strategy ofdiscriminatory food distribution is simply notfeasible because (a) the most vulnerable forma large majority, (b) although not a testedhypothesis, resistance to discriminatory fooddistribution may provoke security incidents

and (c) the social dynamics of the campswould probably ‘rebalance’ food distributionin such a way that the most vulnerable wouldbe no better off.

Targeting food through alternativemechanisms such as food-for-work -including, for instance, skills development andenvironmental improvement - might,nevertheless, be possible on a limited scale.The scope for pilot projects of this kind ismore apparent in Kakuma than in Dadaab. Forexample, water catchment projects forextending vegetable gardens is an area inwhich the Sudanese community in particularmight benefit. However, any infrastructuralimprovement works should be undertakenwith the close co-operation and involvementof the local Kenyan authorities and effortsmade to include the most destitute Turkana insuch schemes.

Income generation

To obtain non-food items refugees must sellpart of their food rations. Most of the NGOtraining programmes are not geared towards‘marketable’ skills within the camps, butrather towards employment skills ‘uponreturn’. The production of low-cost basicitems such as shoes, clothes, soap, etc. has notbeen a priority. Skills training should bereoriented in this direction, with someincentives provided for those participating intraining.

Refugees and the local population

Since the establishment in 1991 of theKakuma refugee settlement the localpopulation has grown from about 5,000 to 30-40,000. In Dadaab, the population has grownfrom about 800 in 1992 to more than 10,000(18,000 in the district as a whole) today. InDadaab, ethnic allegiances (usually along clanlines) and related trading has ensuredsomething of a symbiosis between camp andlocal populations. This is not the case inKakuma. Here, the local Turkana population,following years of successive drought andlack of investment in infrastructure, areconsiderably worse off than refugees. Indeed,food distribution in Kakuma creates a magnetfor Turkana pastoralists (particularly womenand children) keen to benefit from small-scalelabour, petty trading and even begging.

The environmental damage caused by refugeesettlement in Kakuma may have been moresevere than in Dadaab. WFP’s VulnerabilityAnalysis and Mapping (VAM) Unit inSeptember 1999 concluded that food-for-workprojects in areas such as reforestation, watermanagement and sanitation would improveconditions for the local population whilelessening tensions between them and therefugees.

Joint WFP/UNHCR evaluation of Kenyan refugee programmeSummary of report1

1 Summary Evaluation Report of the Joint WFP/UNHCR Evaluation Mission for PRO 4961.04 “Assistance to Somali andSudanese Refugees in Kenya”

2 The SCF-UK Food Economy Updates indicate that this group has increased in the last three years to about 10-15 percent.

26

Field Article

This is the third in a series of pieces publishedin Field Exchange which summarises keysections of the newly revised MSF nutrition

guidelines for use in emergencies (see FieldExchange 10 and 11). This third piece summariseskey principles in the new guidelines for treatment ofsevere malnutrition.

Details on the treatment of severe malnutrition aredescribed in various handbooks, of which “ TheManagement of Severe malnutrition”, WHO 1999, isthe most well known. The MSF guide builds on thisreference work, but develops new thinking on choiceof approach and medical standards.

Key principles for the effective rehabilitation ofseverely malnourished individuals are outlined asfollows:

1. Provide quality nutritional and medical care usingstandard protocols.

2. Use simple and efficient routine medical treatmentfor prevention and management of specificcomplications.

3. Employ standard dietary treatments divided intotwo phases, phase 1 and phase 2.

4. Principles of treatment are the same for all agegroups - children, adolescents, adults and theelderly.

5. Food and drugs should be administered orally orby naso-gastric tube. The use of intra-venousfluids or transfusions, are not part of normaltreatment.

6. Design the programme according to context.

Simple routine treatments

The MSF guidelines advocate the routineadministration of vitamin A, antibiotics, anti-helminths, measles vaccination, iron with malariatesting and treatment (in regions with malaria)regardless of the clinical state of the malnourishedpatient.

It must be noted that all medical treatments shouldbe carried out under the supervision of a physician.

Simplicity is enhanced by:

i) having a focus on drugs which must beadministered over a limited time period;

ii) employing a limited number of weight categoriesfor patients so that drug dosage calculations aremade easier.

The protocols presented in the MSF guidelines strikea balance between cheap and accessible treatmentsand high quality of care. For example, in regionswhere malaria is prevalent, MSF advocates the useon admission of rapid malaria tests (blood smear or

Revised MSFnutritionguidelines IIIBy Saskia van der Kam and SophieBaquet, MSF

The summary below is based upon a nearfinal draft of the new MSF guidelines.1 Theguidelines may therefore undergo somerevision before publication. Furthermore, itshould be noted that certain importantaspects of these draft guidelines do notconform with other currently employedguidelines (Eds).

In 1998, UNICEF initiated a supplementaryfeeding program for pregnant women in theKigoma/Kagera refugee program of Western

Tanzania. The programme which is still ongoingwas implemented in order to reduce theprevalence of low birth weight and improvepregnancy outcome. Prevalence of low birthweight in the camps at the start of theintervention was 30% (Low Birth Weight isdefined as weighing less than 2500g at birth).The main causes of LBW are malaria, HIVinfection, worm infestation and lack of adequatenutrient intake during pregnancy. Womenenrolled in the programme are given a dry take-home ration from the second trimester (from 16weeks gestation age) to delivery. Approximately30,000 pregnant women in eleven refugeecamps are involved in the intervention.

The World Food Program (WFP) provides thesupplementary ration while UNICEF throughoperational partnership with implementingagencies, closely monitors the implementationof the programmes and its outcome.

Ration size and quality

The daily ration comprises 200g of CSB (CornSoya Blend), 20g of vegetable oil and 20g ofsugar per pregnant woman providing a total of1018 Kcal (38g of protein). This is distributedevery two weeks at the nutritionsupplementation Unit. In total it is assumed thata pregnant woman receives about 3180 Kcal perperson per day if the general ration is included(2100 Kcal1 per person per day from generaldistribution).

The weighing, mixing and distribution of thesupplement is normally carried out by thepregnant women themselves, who have beenrecruited onto the programme through theirattendance at antenatal clinics where verificationof gestation age is necessary.

The distribution process

Names are called out by a nutrition attendantwith each beneficiary receiving a “premix” for14 days - about 3.36Kg. As large numbers arealways involved (approximately 400 for a campof 38,000 refugees), a roster for eachblock/village in the camp is used to avoidcongestion and time wasting. Nutritionaleducation (emphasising the nutritional value ofthe supplementary ration) and cookingdemonstrations are frequently conducted at thedistribution site.

Main findings and lessons learnt

The programme has contributed to a reductionin low birth weight in the camps. Prevalence of

LBW has decreased from 30% to 8.5 - 10% indifferent camps. These results are similar to astudy in Gambia in 1997 where a 50% reductionin LBW was observed after supplementationwith groundnut-based high energy biscuits(providing 1000 kcal per person per day).

The success of the program is mainly due toclose cooperation between the pregnant womenthemselves, the service providers at theantenatal clinic and the personnel at thesupplementary feeding units.

Added impacts and benefits of theprogramme

• the women organise themselves and take astrong leadership role in nutritional aspects ofthe programme.

• an improved attendance of pregnant women atthe antenatal clinics with coverage reachingalmost 100%.

• an increased number of pregnant womenreceiving malaria prophylaxis, de-wormingand iron supplementation (at the ante-natalclinic).

• an earlier enrolment in the ante-natalprogramme resulting in earlier identificationof pregnancy risk factors.

Programme Constraints

• It has been difficult to evaluate programmeeffectiveness as allocation of a dry take homeration has meant that actual consumption byintended beneficiaries is uncertain, i.e. someof the ration may be consumed by otherhousehold members.

• The effectiveness of the programme has beencompromised due to interruptions in thegeneral ration food pipeline (i.e. to beoptimally effective supplementary feedingprogrammes need to supplement an adequategeneral ration). For example, as of July 2000,there has been a 40% cut in the general ration.This was the first time the general rationsupply had been compromised during theprogramme. While the supplementary feedingof pregnant women has continued during thisperiod there has been a drop in overall intakefrom 3180 Kcal to 2522 Kcal per pregnantwomen per day (a drop of about 20%).

1 Comprising of 360g maize meal/grain (410g), 120gpulses, 40g CSB and 20g vegetable oil per person perday (pppd). An additional 50 g of maize is provided tooffset the milling costs and wastage totalling 410gpppd.

Feeding the unborn babiesBy Severin Kabakama

Dr Severin Kabakama (MD Dar) is Assistant Project Officer (Early ChildDevelopment) in the Western Tanzania Refugee Program, UNICEF KasuluField Office. He has worked for twelve years as medical officer inTanzania (of which 5 year have been spent with the Rwandese,Congolese and Burundian refugee programs in Western Tanzania)

27

Guidelines

rapid field test) for all children and pregnant women.Where diagnosis is confirmed treatment with acombination of two drugs is necessary (e.g. artisunateand fansidar/mefloquine). The reasoning is thateffective treatment at individual and public healthlevel is in the end more efficient with adherence tooptimal but more expensive protocols (routine testingand dual drug therapy). Furthermore, by employingthese protocols while maintaining an on-goingdialogue with the pharmaceutical companies aboutreducing prices of essential drugs, MSF hopes toeventually make these effective treatments accessibleto other agencies and health institutes that cannotcurrently afford industry prices.

Simple Standard Diet

Standard dietary treatment provides for a gradual andbalanced re-introduction of energy, proteins and othernutrients. Specialised food items (F-100, plumpynut,fortified blended food, CSB, WSB, UNIMIX, BP5etc.) are used to provide a balanced diet.

In phase 1 of therapeutic feeding MSF advocates theuse of F-100. This contrasts with some otherguidelines which advocate the use of F-75. This isbecause the use of an even more specialised milk forthe first phase (F-75) will be difficult to manage inmany of the settings where MSF operates, e.g. inconflict situations where it may be difficult to findexperienced staff. The benefits of using F-75(lowered osmolarity) as well as F-100 may notoutweigh the risk of mistakes. Patients in phase 1could receive F100 in the amounts meant for F75which leads to a risk of over-feeding. Similarly, ifpatients in phase 2 receive F75 in quantities meantfor F100 then caloric intake will be reduced. The useof F-75 increases work load considerably for staffand competes with other vital activities in TFCs. Thenew MSF guidelines therefore advise that F-75should only be used in therapeutic feeding centres ifthe centre is well organised so that the risk ofmistakes are minimised.

Treatment phases

Treatment of severe malnutrition is divided into twophases - phase 1 and phase 2.

The division into phases indicates a change in dietand the intensity of monitoring of the individualpatient. In phase 1 the metabolism of a severelymalnourished individual has to be restored so theycan then metabolise larger amounts of food in Phase2. During Phase 1 the patient should be closelymonitored for signs of complications. The transferfrom phase 1 to phase 2 should be based on clinicalassessment of the patient, (i.e. are they responsive,lively and interested?).

Additionally all of the following criteria should bemet:

• Recovery of appetite (patient asks for more food,patient finishes the bowl).

• Absence of oedema or grossly decreased oedemaafter 7 days in phase 1.

• No severe medical complication (severedehydration, severe anaemia, severe infection).

• Maximum stay in phase 1 is 7 days (exceptions canbe made for individuals in rare cases).

The move from Phase 1 to Phase 2 should take placeat mid-day, in order to achieve a gradual increase inthe amount of food consumed. Some agencies have aseparate phase for this transition with a total of threephases in the centre. However this may introduce arisk that patients stay longer than necessary ‘intransition’, and that the crucial individual monitoringof patients in transition is replaced by a standardnutritional protocol.

A premature transition from phase 1 to phase 2 canlead to over-feeding syndrome, congestive heartfailure (see above) and increased oedema (orpersistent oedema in phase 2).

The syndrome associated with over-feeding is causedby hypervolemia combined with electrolyteimbalances. This leads to kidney, heart and intestinalsystem overload, which can lead to a fatal congestiveheart failure. Typical causes of over-feeding are:

• Excess volume of food (and liquid) during onemeal (e.g. early transfer to phase 2; an adult patienteating more then prescribed)

• A high protein diet (> 16% of Kcal provided byprotein)

• A diet high in sodium (either through the use ofexcess RESOMAL or ORS or from food offered byfamily members)

The signs of over-feeding syndrome include:

• an increase or the (re-)appearance of oedema • in severe cases, the rapid development of

congestive heart failure

All age groups

The principles of treatment (food and drug types) areapplicable for all age groups - children, adolescents,adults and the elderly. Differences include:

• for adults treatment with antibiotics is notsystematic but is carried out only on prescription,i.e. on demonstrating symptoms or having specificcomplaints for which treatment is prescribed by thedesignated medical person

• measles vaccination is not necessary for adults• systematic malaria testing of adults is not necessary

Dosages of medical and nutritional regimes willdiffer depending on the weight and age ofindividuals. For dietary treatment adults should beplaced in groups according to weight and phase oftreatment in order to (as much as possible) giveadults similar amounts of food. This is to reduceworkload for staff and reduce risk of over/under-feeding of the patient.

IV and Naso-gastric tube

Food and drugs should be administered orally or bynaso-gastric tube. A naso-gastric tube should be usedwhen there is:

• complete anorexia• severe dehydration• inability to drink and eat (too weak, consciousness

impaired)• severe or painful mouth lesions (candidasis) • repeated, very frequent vomiting

Patients with a naso-gastric tube should be placed inan area which facilitates close monitoring by medicalstaff.

The use of intra-venous fluids or transfusions is notpart of the normal treatment. The only indication forinfusion in severe malnutrition is when the risk ofacute cardiac failure is high due to circulatorycollapse (severe dehydration or septic shock) or alife-threatening anaemia.

In some cases, intramuscular (IM) injections arenecessary. Care should be taken to carefully select thesite of each IM injection.

Programme Issues

Setting up a TFC is justified when there is a foodcrisis or famine with large numbers of severelymalnourished patients. The sole objective of the TFCis to reduce mortality due to malnutrition in thecommunity. Outreach workers should actively searchfor patients in the community as well as tracedefaulters. Additionally, efforts should be made withthe community to identify and tackle the causes ofthe food crisis and malnutrition.

In non-emergency situations there may be a limitednumber of severely malnourished individuals(children, adolescents and adults). These individualswill often have a history of disease and social andeconomic marginalisation. These patients also needtreatment which should be offered in existinghospitals. The principles that are outlined above forTFCs also apply to hospitals; however hospital staffwill need thorough training in treatment of severemalnutrition. In addition discussions with individualsand their families should take place to identify thecauses of malnutrition and possible solutions for thatindividual. It should be recognised that it may not bepossible to have an active case finding, defaultertracing nor a programme component aimed atreducing severe malnutrition in the communitythrough hospital programmes. This may need to benegotiated with the Ministry of Health andCommunity Health Programmes (if these exist).

In situations where there are only a few cases of adultmalnutrition, they can be treated in TFCs whichtarget children or in a hospital.

Design of TFC

Ideally a TFC has a 24-hour care unit where cases inthe first phase are treated and where patients in thesecond phase with medical complications are treated.However, when first opening a TFC, especially wherethere are large numbers of patients (e.g. in a faminesituation), the TFC should at first set up day-careonly. As soon as the situation stabilises and capacityis adequate, then 24-hour care can be started. Whenthe number of patients is large, the nutritionalcomponent of the treatment can be standardised onthe basis of individuals being placed in weightcategories/groups and groups requiring intensive orless intensive monitoring. These simplifications makeit easier to provide patients with adequate care at atime when resources may be stretched withoutcompromising management or exhausting the staff.

Authors of the MSF nutritional guidelines: Sophie Baquet,Saskia van der Kam, Jane Little, Veronique Priem, FabienneVautier.

Naso-gastric tube administration

• Care should be taken to explain the necessity ofthe naso-gastric tube to the mother or patient soit is accepted and not pulled out.

• Before each meal by tube, first try to breast-feed or feed by mouth

• To avoid the risk of broncho aspiration, patientswith a naso-gastric tube should be positioned ina semi-sitting position (45 degrees)

• Naso-gastric feeding should not be carried outfor more than 3-4 days. Before each use, alwayscheck placement (that tube is still in thestomach), to avoid risk of broncho-aspiration.The tube should be changed every 48 hours.

Quantity of food in Phase 1 and Phase 2 (per day)

Age Group Phase I Phase II(Minimum quantity)

Child - 10 yr. 100 kcal/kg/day 200 kcal/kg/dayindividual calculation

Adolescent 10-18yrs 55 kcal/kg/day 100 kcal/kg/daymin. 3000 kcal/p/d

Adult + elderly >18yrs 40 Kcal/kg/day 80 kcal/kg/daymin. 3000 kcal/p/d

Signs of congestive heart failure:

• increase in respiratory rate• increased pulse rate• engorged jugular veins• increased oedema (i.e. puffy eyelids)• pulmonary congestion (crackles in lungs)• cold hands and feet, cyanosis in fingertips and

lips

Monitoring of weight during rehydration willhelp early diagnosis, e.g. sudden increase ofbody weight

While Kenya is one of the more developedcountries in Africa, it has lagged farbehind most in development of a national

early warning system and coordination in the foodsecurity sector. As late as 1998, the Government ofKenya (GoK) had two donor funded earlywarning/food security projects - Arid Lands ResourceManagement Programme (ALRMP) and DroughtPreparedness, Intervention and Recovery Project(DPIRP) - covering the ten almost exclusivelypastoral districts in Northern and Eastern Kenya.However, the GoK had little capacity forcomprehensive early warning or coordination of foodsecurity activities in other areas of the country. Inaddition, within the central government, it was veryunclear as to who/which structure had responsibilityfor early warning and food security coordination andanalysis.

Outside of the GoK, a plethora of internationalorganisations (donors, UN agencies and NGOs) wereindependently conducting their own early warningand food security data collection and analysis. Theresult of these activities and systems was:

i) a large amount of inconsistent and sometimesmisleading information that was confusing todecision makers;

ii) the development of parallel systems - one in theGoK and others among international organisations -for implementing food security related emergencyand mitigation activities.

This situation was unacceptable to donors and manyothers who felt that as a result of the poorcoordination, the effectiveness of interventions waslimited and financial and other resources were notbeing used efficiently.

Formation of the Kenya Food SecuritySteering Group

In late 1998, the World Food Programme (WFP) andthe GoK in agreement with donors and other partnersdecided to change the function and structure of anexisting WFP-chaired, semi-monthly forum to shareinformation on emergency interventions to make itmuch more systematic, efficient and action-oriented.It was also decided to broaden the forum’s scope toinclude early warning and comprehensive foodsecurity situation updates and analysis. To this end,the members of the revitalised forum, which becamethe Kenya Food Security Meeting (KFSM), agreed tocreate and nominate members for a steering group.This steering group first called the Kenya FoodSecurity Information Steering Group and laterrenamed the Kenya Food Security Steering Group(KFSSG) at the request of the GoK, led the effort todevelop a systematic, comprehensive and multi-agency early warning, food security status monitoringand assessment system for Kenya.

The KFSM meets monthly, includes representativesfrom over 50 different organisations (GoKdepartments, UN agencies, donors and NGOs) and isopen to all organisations with an interest in foodsecurity. The KFSSG is a subset of the KFSM andcurrently includes representatives from three GoKdepartments, three UN agencies, three NGOs and twodonors. Membership of the KFSSG is restricted toorganisations which have demonstrated a clearcommitment to a collaborative approach and which

possess technical, policy or administrative capabilityin the area of food security and drought management.The GoK requested the name and scope change ofthe KFSSG (from KFSISG) because it was extremelyhappy with the progress made and felt that themandate of the KFSSG should be to coordinate morethan just the information system.

Formation and Role of Geographic ReviewTeams

The other structures that were created early on in thisprocess were the Geographical Review Teams(GRTs). The GRTs ensure that up-to-date earlywarning and food security status monitoring data andreports covering the entire country are available tothe KFSM and KFSSG on a monthly basis. Theyprovide an opportunity for organisations that mayhave relevant data for a small area (such as NGOs) tofurnish and discuss that information in ageographically specific group that ensures it isconsidered in the production of the situation reportfor the larger zone. This alleviates the necessity ofhaving every local organisation present at the KFSMand endless reports at the KFSM on organisationalspecific assessments, activities and initiatives. Thereare five GRTs that cover different administrative-livelihood zones - northwestern pastoral, northeasternpastoral, agro-pastoral, marginal agricultural andhigh-potential/dairy districts - across the country. TheGRTs have a focal point and are composed oforganisations with capacity and/or interest inactivities in the zone covered by the GRT. They arecharged with collecting and analysing all relevantdata, developing a consensus among the members ofthe GRT, putting together a situation report based onthis consensus position and presenting that report atthe KFSM. They also have responsibility forreporting on the major interventions, reviewingproposals for funding for activities and providingrecommendations for action and/or interventions stillneeded in their zone.

Outcomes of Improved Co-ordination

The creation of this Kenya Food Security CoordinationSystem (KFSCS) greatly facilitated the developmentof important joint initiatives. Multi-agency foodsecurity assessments became the norm, andcoordinated field assessments are conducted on aregular basis. WFP and the NGOs agreed to transportGoK food aid as well as that from WFP. The GoK hasmade substantial pledges to WFP EMOPs (EmergencyOperations) and the GoK has agreed that all the foodis placed in a single pipeline. The KFSCS agreed thatthe Community Based Targeting Distribution system(CBTD) should be used for the EMOP and the GoKmade the CBTD system the law of the land. As aresult, the previous ineffective and sometimes corrupttargeting and distribution system administered by GoKDistrict Commissioners was shelved and the muchmore effective, grass-roots based CBTD system run byelected, gender-balanced relief committees wasadopted and implemented throughout the country. Aseries of missions have indicated that the KFSCS andCBTD initiative combined have revolutionised foodaid targeting and distribution in Kenya and ensuredthat vulnerable populations in all areas covered by theEMOP have received adequate food. In addition, alarge number of Kenyans like the new systems andfeel empowered by it.

Development of Kenya Food SecurityCoordination System (KFSCS)by Robin Wheeler

Robin Wheeler has been WFP’s Regional Vulnerability Analysis and Mapping (VAM) Officer forthe Horn of Africa based in Nairobi since October 1998. He was the USAID/FEWS CountryRepresentative in Ethiopia (1996-98) and Niger (1991-93), and held positions with USAID as agovernment advisor in Guinea (1994-95) and an emergency coordinator in Niger (1991).

28

Field Article

RegistrationR. Wheeler

DistributionR. Wheeler

DistributionR. Wheeler

A Model for Co-ordination in Other Sectors

In May-June 2000, the UN system was required toproduce a Consolidated Appeal (CAP) for Kenyacovering the July-December 2000 period. The foodsector was well coordinated so that WFP, the GoKand their partners had already reached agreement onwhat resources were required and the numbers thatwould go into the CAP. However, there had beenlittle consensus developed on needed interventions inother sectors. Therefore, at the request of the UNagencies concerned with these other sectors and theGoK, the KFSCS was used and multi-agencySectoral Groups for Agriculture and Livestock,Health and Nutrition and Water and Sanitation werecreated within the system to meet and developconsensus reports and numbers for the CAP for thesesectors. The result was that the UN CAP and GoKappeal were exactly the same and donors generallyresponded very well, funding many previouslyunfunded initiatives. Following completion of theCAP it was decided that these Sectoral Groupsshould be maintained and strengthened, so that thesame kind of consensus that existed in the foodsector could be extended to other emergencyinterventions and preparation of documents like thenext CAPs would be facilitated. As such, theseSectoral Groups now provide technical backstoppingand set standards within their respective sectors fordata collection, analysis, assessments, surveys andinterventions.

The UN System in Kenya in conjunction with theKFSCS produced another consensus-based CAP forthe January-June 2001 period in December 2000.The background analysis and contingency scenariosin that document were derived from a Kenya FoodSecurity Situation Report produced by the KFSSGduring that same month. The information containedin this document came from the KFSSG members,GRTs and Sectoral Groups.

Lessons Learned

Key principles

In terms of lessons learned, the major principles usedin creating the KFSCS, which led to its success andmay be transferable to other countries are:

1. Development of a forum (the KFSM in Kenya)and a system that enables all interested and relevantinstitutions to have input into the development of thesystem, have access to the same complete earlywarning and food security information andcollaborate and coordinate their activities in thesector;

2. Creation of a steering committee for the system,with dedicated members, which drives it and ensuresthat it continues to develop in a positive way;

3. Establishment of GRTs which ensure that relevantfield information is brought into the system on a veryregular basis and institutions, such as NGOs, whichcover small geographical areas, but may have verydetailed and relevant information, have input, yet donot take large amounts of time giving independentreports at the country-wide forum;

4. Creation of sector groups that ensure that technicaldetail is considered, but not in the larger forum, andthat the relevant group of technical people areinvolved in the discussions and decision makingrequired in the sector;

5. Involvement in the system of government or incases where government is lacking, other authoritieson the ground; and

6. A willingness by all involved to think broadly andgo beyond the immediate needs of their individualagency working towards getting the overall tasksdone in the most effective and efficient way possible,using the principle of comparative advantage.

Tanzania has already used these principles gleanedfrom the Kenya example to begin creating its ownfood security coordination system, while southernSudan and Uganda have both expressed interest and

are about to begin efforts to create similar systemsbased on these principles.

In the longer term, it is certainly hoped that the GoKwill develop a national early warning system withlong-term capacity and extensive coverage of thecountry as well as national structures with a clearmandate for coordination in the food security sector.However, the support and involvement of theinternational community throughout this process willbe necessary, and the development and operations ofthe KFSCS have filled a dangerous vacuum thatexisted and would have prevented an adequateresponse to the devastating drought that has crippledKenya during the last three years.

Remaining Challenges

The experience in development and operation of theKFSCS has been largely positive, but it has not beenwithout its difficulties and challenges. While theanalysis and dissemination of food securityinformation is now generally well coordinated at thenational level, relevant, up-to-date, monthly foodsecurity information is still lacking from some areasof the country. This is particularly true for themarginal agricultural and agro-pastoral areas ofKenya and can be attributed to poor NGO coverageof many of these areas, and sometimes an inability orunwillingness by some field-based projects andNGOs to contribute regularly to the system.

The involvement/participation of organisations withinthe KFSCS is completely voluntary. During thecurrent emergency, strong participation in the systemby a myriad of organisations has at least beenpartially driven by a healthy dose of vested interest,since donors tied much of their emergency funding toparticipation in the KFSCS. As we hopefully movefrom an emergency to recovery and back to adevelopmental phase in Kenya in the next year or so,it will be a challenge to ensure adequate involvementby key organisations in the different structures of theKFSCS and maintain the momentum of the last twoyears.

The KFSSG and its sub-groups have accomplished agreat deal over the last two years, but its efficiencyand effectiveness have been hampered by the lack ofany permanent or seconded staff. All members of theKFSSG, and for that matter the KFSCS, have full-time jobs with their respective agencies, and KFSSGactivities are additional to their already full

workloads. Until the KFSSG has at least a permanentsecretariat and preferably at least one technicaladvisor, it will be limited by the ability andwillingness of its members and organisations tocontinue working overtime to achieve globalobjectives in addition to their own organisationalobjectives. In the longer run it is unlikely that theKFSCS will be sustainable without some permanentstaff. The KFSSG has recognised this and hasproposed that, to begin with, two staff from the GoKbe seconded to the KFSSG to act as its secretariat.

While most agencies in the food security sector areenthusiastic members of the KFSCS, someorganisations insist on continuing to performindependent assessments with non-standardmethodologies and, particularly in the non-foodsector, intervening in a un-coordinated way. Thismakes their assessment findings difficult to comparewith data from the KFSCS, and can lead to differentresults and confusion about the real situation on theground as well as unnecessary duplication andinterventions with over-lapping purposes.

With strong support from WFP and the GoK, theKFSCS extended its coordination to food aidtargeting, logistics and distributions at all levels inareas covered by the WFP Emergency Operation(EMOP). During February 2001 this involved 22districts and 86 percent of the land area of Kenya. Asnoted above, the GoK has provided a large portion ofthe maize for this operation through pledges to theWFP EMOP. However, the GoK has also continuedfood aid distributions on its own in ‘pockets’ ofapproximately 23 other districts in Kenya, notcovered by the EMOP and until recently, not part ofthe monthly KFSSG/Food Aid Estimates Sub-Group(FAS) review of needed allocations. In coordinationwith its partners, the GoK has recently tried to rectifythe continuation of a dual food aid targeting systemby bringing information on theseallocations/distributions to the attention of the FAS,and asking that global food aid targeting in the ‘GoKprovided-for districts’ be performed in the same wayit is for EMOP districts. The GoK has also beenattempting, with varying degrees of success, toimplement CBTD in these areas. In addition, theJanuary 2001 Food Security Assessments in Kenya,coordinated by the KFSCS, covered 15 EMOPdistricts, and, at the request of the GoK, the fivedistricts receiving the most food aid from the GoK.

29

Field Article

Kenya Food Security Meeting (KFSM)

Kenya Food Security Steering Group (KFSSG)

Sectoral Working Groups (SWGs) Geographical Review Teams (GRTs)

Northwestern Pastoral Team

Northeastern Pastoral Team

Agro-Pastoral Team

Marginal Agricultural Team

High Potential Team

Food Aid Estimates Sub-Group

Health and Nutrition Sub-Group

Water and Sanitation Sub-Group

Agriculture and Livestock Sub-Group

Education Sub-Group*

* Education sub-group only in place since January 2001.

Notes: • The flows within the system – downward arrows indicate guidance, while upward arrows indicate

sharing of information from the relevant working group.• All donor, GoK, UN and NGO partners may participate at all levels of the coordination system.

Kenya Food Security Coordination System

30

Left Column, top to bottom: Susan Mwangi (AMREF) hard at work; Ambra Longatti (CaritasItaliana) and Abel Samperiz (Intermon - MRDA) in the meeting room at Intermon; Esther Wamai(nutritionist, Christian Children’s Fund); Dolline Busolo (regional nutritionist, HelpAge) happy atwork; Peter Mutori (project officer, Kakuma refugee camp) and Bobby Waddell (Representative,LWF) enjoying the photo shoot; Dr. Imanol Berakoetxa, coordinator of the Somalia AidCoordination Body - before filing.Middle Column, top to bottom: Paula (Concern) and Kathleen (GOAL) on a well deserved day off;Evaline Were-Diang’a and Allen Kute (VAM) analysing food security information, WFP Nairobi;Emily Mwadime and Alison Maccoll (FAO Somalia) in denial of the photographer; Edward Onita(planning, monitoring and evaluation officer, ADRA Kenya) delighted to discover Field Exchange.Right column, top to bottom: Clemensia Mwiti (nutritionist, World Vision, Kenya) at the office;Tanya Khara (nutritionist, Concern Worldwide) writing up their Turkana assessment; Helen Young(Tufts University) and Zlatan Milisic (WFP-OLS coordinator) at the nutrition training held in Kenya(photo: Anne Callanan); Eva Magondu and Manisa Zaman holding the fort while colleaguesPenina Muli, Senewa Montet and Sarah King carry out nutritional surveys, The Emergency Healthand Nutrition Group, UNICEF Kenya.

All photographs taken by Joyce Kelly in Nairobi, Kenya, February 2001, unless otherwise stated.

People in Aid

The Emergency Nutrition Network (ENN) grew outof a series of interagency meetings focusing on food andnutritional aspects of emergencies. The meetings were hostedby UNHCR and attended by a number of UN agencies, NGOs,donors and academics. The Network is the result of a sharedcommitment to improve knowledge, stimulate learning andprovide vital support and encouragement to food and nutri-tion workers involved in emergencies. The ENN officiallybegan operations in November 1996 and has widespread sup-port from UN agencies, NGOs, and donor governments. Thenetwork aims to improve emergency food and nutrition pro-gramme effectiveness by:

• providing a forum for the exchange of field level experi-ences

• strengthening humanitarian agency institutional memory • keeping field staff up to date with current research and

evaluation findings• helping to identify subjects in the emergency food and

nutrition sector which need more research

The main output of the ENN is a quarterly newsletter, FieldExchange, which is devoted primarily to publishing field levelarticles and current research and evaluation findings relevantto the emergency food and nutrition sector.

The main target audience of the Newsletter are food andnutrition workers involved in emergencies and those research-ing this area. The reporting and exchange of field level expe-riences is central to ENN activities.

The ENN is located in the Department of Community Healthand General Practice, Trinity College, Dublin, Ireland.

The TeamFiona O’Reilly is the ENN Co–ordinator, and FieldExchange co–editor. Fiona has been involved inthe area of nutrition, health and development forthe past 10 years, half of which has been spentworking in emergency situations.

Jeremy Shoham is co–editor for Field Exchangeand the ENN technical consultant. Jeremy hasbeen working in the area of emergency food andnutrition for the past 15 years.

Joyce Kelly joined the ENN in January 2001 andworks as part of the Field Exchange editorialteam. She has been involved in health, nutritionand food security programmes for seven years,half of which has been spent working in emergen-cy situations.

Kornelius Elstner works part time with the ENN.

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The Backpage

Field Exchange The

supported by:

EditorsFiona O’ReillyJeremy Shoham

Layout & WebsiteKornelius Elstner

Contributors for this issuePatricia AraruKen BaileySophie BaquetBuwa DragudiSeverin KabakamaSaskia van der KamMike ParkerKate SadlerDianne StevensRobin Wheeler

Thanks for the Photographs to:Ken BaileyKyla Barber (HelpAge)Lucy Deering (Concern)Anne Kellner (UNHCR)Mike ParkerPieternella PieterseDianne StevensRobin Wheeler

On the coverUnloading of rice supplied by WFP. Itwill be distributed at differentcollection points in Dili, the East Timorcapital. (UNHCR / M. Kobayashi)

As always thanks for the Cartoon to:Jon Berkeley, who can be contactedthrough www.holytrousers.com

Special thanks to Professor JohnKevany, Jean Long and Deirdre Handyfrom Trinity College for assistance andsupport for the ENN.

Pandamonium by Jon Berkeley

UNHCR

GENEVA FOUNDATIONto protect health in war

Royal Danish Ministry of Foreign Affairs

Emergency Nutrition NetworkDepartment of Community Health & General PracticeUnit 2.5, Trinity Enterprise Centre,Pearse Street, Dublin 2, Ireland

Tel: +353 1 675 2390 / 843 5328Fax: +353 1 675 2391e–mail: foreilly@tcd.iewww.tcd.ie/enn